Drugs for Migraines: Acute Treatment Strategies

I wish I could send every migraineur this page of drugs for migraines listing the possible acute treatment combinations. 

Drugs for Migraines: Acute Treatment Strategies

The NSW Therapeutic Assessment Group has provided a fantastic summary on what drugs to take during an acute attack.

It is not in lay-mans terms, so I have broken it down for us to understand easier.

This article from the Australian based © NSW Therapeutic Advisory Group lists the medications for migraines at each stage of severity.

This has been reproduced with permission of www.nswtag.org.au and has been copied directly in its “unaltered, complete form” as per their copyright policy with the exception of me leaving off the level codes for the 4 levels of evidence due to illegibility. The writing is already small enough.

The levels of evidence were mostly obtained from review of randomized controlled trials or from experts in this field. Please click on the article link MIGRAINE to read more details.

Stage of Migraine


Other Options

  Early /

  mild migraine

Aspirin 600-900mg initially followed by 600 mg every 4 hours


Paracetamol 1000mg orally then 

Paracetamol 1000mg every 4 hours

(max 4g Paracetamol per day)


Metoclopramide 10 mg orally or

Prochlorperazine 5 mg orally

Metoclopramide will improve gastric emptying which may be desirable for some patients.

Prochlorperazine will cause greater sedation (which may be desirable for some patients).

Naproxen 750 - 1250mg


Ibuprofen 400 - 1200mg


Diclofenac 50 - 100mg

Use one to two doses only. Avoid NSAIDs, including COX-2 inhibitors, in patients who are volume depleted, elderly or have renal dysfunction. Avoid conventional NSAIDs in patients with a history of peptic ulcer disease.

Domperidone 20 mg may be useful for patients with a history of dystonic reactions to phenothiazines or metoclopramide

  Persistent /

  moderate to severe migraine

  Able to tolerate oral medication

Aspirin 900 mg followed by Aspirin 600 mg every 4 hours


Ergotamine 1-2 mg orally as an initial dose
(not exceeding 10 mg per week)


Sumatriptan 50-100mg orally (if there is no response 

to 100 mg a second dose will NOT be effective)*


Metoclopramide 10 mg orally or prochlorperazine 5 mg orally

*see general discussion

Naratriptan 2.5mg orally


Zolmatriptan 2.5-5mg orally

  Persistent /

  moderate to severe migraine

  Unable to take oral medication

Dihydroergotamine 0.5-1mg SC, IM or IV
Metoclopramide 10 mg IM or IV or prochlorperazine

12.5mg IM


Sumatriptan 6 mg SC. A second dose may be given after one hour but only if there is a response to the first dose
Metoclopramide 10 mg IM or IV or prochlorperazine 12.5mg IM

OR, if in a monitored environment,
Chlorpromazine 12.5-25mg IV or IM* (Note sedative and hypotensive effects. IM injection can cause sterile abscesses).

*see general discussion

Ketorolac 30-60mg IM*

Intranasal sumatriptan 20 mg

Prochlorperazine suppositories may be useful when oral medication is not tolerated.

*see general discussion

  Severe migraine

  and patient has taken ergotamine

  or triptan without effect

If in a monitored environment

Chlorpromazine 12.5-25mg IV or IM* (Note sedative

and hypotensive effects.

IM injection can cause sterile abscesses).

Chlorpromazine has been shown in small RCTs to be at least as effective as dihydroergotamine, sumatriptan (unblinded study), ketorolac and pethidine plus promethazine.

*see general discussion

Ensure adequate hydration

Paracetamol or NSAID

If ergotamine trial ineffective, wait 6 hours and try sumatriptan. If triptan trial ineffective, wait 24 hours and try ergotamine.

If necessary consider opioids.

  Migraine during pregnancy

Paracetamol 1000mg orally or rectally every 4 hours


if in a monitored environment,
Chlorpromazine 12.5-25mg IV or IM*
(up to week 32)

*see general discussion, pages 4-5.

Ensure adequate hydration

Add prochlorperazine
(to week 32)


(after week 32)

This article does not recommend Pethidine or Lignocaine for migraines. Also, the paper is a bit old now, 2002, but these medications are all still used. So I think it's important.

Other Important Things To Consider Around Taking Drugs For Migraines

Drugs for Migraines - Acute Treatment Strategies

The other important things we must consider as migraine sufferers around the drugs for migraines we take are:

• Discuss early treatment to reduce as many symptoms as possible and cover self management of your acute medications with your doctor.

• Visit the doctor regularly if your episodes are frequent to discuss if you need prophylactics.

• Keep a list of your symptoms and any “overlapping pain syndromes” after the migraine attack. Things like a tension headache, or possible rebound headache from your prescribed drugs for migraines or over the counter pain killers.

• Try to determine the efficacy of the medications you are trialing.  Perhaps use a rating scale and include: duration of pain relief, how long the tablet takes to effect your pain, if there was any breakthrough pain during the attack, how long the pain is stopped for, is it stopped or just reduced.

• Prepare a treatment strategy with your doctor. If they do not have a plan, you will find a few different ones to use here in our help for migraines tool kit.

• Ask your doctor how to measure your results and what to watch for from the drugs for migraines they prescribe for you.

• Know your limits and ask for help if this is all too overwhelming. You can ask the pharmacist or just visit the doctor until you feel clear about what to take and when.  Being clear will save you from any accidental overdoses. I use my little pink card system - for more details please see my supplements for migraines article.

It's Trial and Error to Find What Works

Here in Australia they recommend Paracetamol (Acetaminophen) which I can’t take because it makes me more nauseous (see my migraine pain medication failed list - if you'd like). After trialling every pain killer on the market, I found Ibuprofen to be most effective at catching the pain with an abortive, that is.

My advice – it could be a bit of trial and error when it comes to finding the right drugs for migraines. But all I can say is persevere! There is a huge selection available to you now and it is worth finding what works. This table above is an excellent resource.

I gave up on finding an effective medication far too easily and turned to alternative therapies for help. I turned my back on migraine medications for over ten years when I thought I could meditate the pain away or heal myself. Back then, I was consistently told by each and every practitioner that I saw to think positive and that what they had to offer would work.

I was able to learn to meditate the pain away – or was it until I passed out from the pain, which is probably more likely - but getting back to reality after 10 days of meditation on a regular basis was quite difficult for me. Especially around work, and very few friends understood.

Find what works and then choose if you want to use drugs for migraines first. At least when it comes down to it, you will know what works for you. Persevere my fellow traveler, you will find pain relief.

Other Ways to Treat Migraines Effectively

Studies are now saying that the best way to deal with a migraine attack is to combine traditional drugs for migraines with alternative and complementary therapies.

And I would add to educate yourself. This is essential. Here is more reading:

Reference: NSW Therapeutic Assessment Group (2002) Migraine. [Online], Available at: http://www.ciap.health.nsw.gov.au/nswtag/publications/guidelines/Migraine41202.pdf - Accessed 12 March 2012.

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