Doctors use a combination of over-the-counter (OTC) pain relievers and prescription-only formulations to manage migraine symptoms that come on quickly.
The strongest remedy for you depends on how long your episodes last and what drugs have worked for you before.
Strongest oral migraine medicines
During a migraine episode, cranial arteries are open wide, causing pain. Triptans are first-line treatments for migraine. They work on serotonin receptors to help narrow the widened arteries, relieving the pain.
While some triptans might be available in higher doses, these may also have lower bioavailability. This means they may be less effective at entering your bloodstream and actively doing their job.
A lower dose of a drug with a higher bioavailability may be more effective as your body absorbs more of the drug.
Other factors include drug half-life. This helps you understand how long it will take for a drug to work in your body and how long the effects may last. While one drug might provide quick relief, the effects may wear off faster than a drug that takes longer to work. However, the desired effect lasts longer in drugs that take longer to work.
There are seven triptans. Each works at different speeds and is for different types of migraine episodes. They include:
- Almotriptan (Axert): This becomes effective 1–3 hours after taking it. It is the only triptan approved for use in adolescents.
- Eletriptan (Relpax): Doctors and healthcare professionals may prefer to prescribe this medication for long lasting migraine attacks. This is because it has a long half-life, which means it stays in your system longer.
- Frovatriptan (Frova): This has the longest half-life of any triptan at 26 hours. However, it may take longer to feel the effects.
- Naratriptan (Amerge): This is another option for moderate and long lasting migraine episodes.
- Rizatriptan (Maxalt): This is the fastest-working triptan. It takes about 30 minutes to feel the effects. However, it also has the shortest half-life, as you may only feel the effects for around 2–2.5 hours. It is an option for severe migraine episodes that may be shorter in duration.
- Sumatriptan (Imitrex): This has low bioavailability at about 15% in its oral formulation. The half-life is about 2.5 hours.
- Zolmitriptan (Zomig): This has a half-life of around 3 hours.
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Oral triptan dosages
The table below lists the available dosages of oral triptans.
| Drug name | Dosage |
|---|---|
| almotriptan (Axert) | 6.25 milligrams (mg) and 12.5 mg |
| eletriptan (Relpax) | 20 mg and 40 mg |
| frovatriptan (Frova) | 2.5 mg |
| naratriptan (Amerge) | 1 mg and 2.5 mg |
| rizatriptan (Maxalt) | 5 mg and 10 mg |
| sumatriptan (Imitrex) | 25 mg, 50 mg, and 100 mg |
| zolmitriptan (Zomig) | 2.5 mg and 5 mg |
Triptans as a whole have common side effects, such as:
- chest, throat, or jaw tightness
- feeling like your arms and legs are heavy
- fatigue
- muscle aches
Less common side effects include:
- dizziness
- mental fog
- weakness
- a prickly sensation on the skin
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Get free cardStrongest injectable migraine meds
Dihydroergotamine (D.H.E. 45) works on neurotransmitter receptors. Researchers don’t yet fully understand how this drug is effective, but two theories are that it reduces inflammation or causes cranial blood vessels to constrict.
D.H.E. 45 is available as an intravenous (IV) infusion or injection. A healthcare professional can inject it intramuscularly, in the muscle, or subcutaneously, under the skin.
Via IV, the dose is 1 milliliter (mL) at 1-hour intervals for a maximum of 2 mL in 24 hours. Via injection, this increases to 3 mL in a 24-hour period.
A doctor or healthcare professional may start you at a lower dose of 0.5 mL. You will typically receive D.H.E. 45 with a medication that helps with nausea and vomiting, as this is a common side effect. The drug may also make you feel uneasy.
Medicines given in the ER for migraine
If you have an acute migraine episode that lasts more than 72 hours, you might receive a combination of medications in the ER. The exact combination depends on your medical history and what drugs have worked for you in the past.
The American Headache Society (AHS) recommends that medical professionals in the ER should offer IV metoclopramide (Reglan) and prochlorperazine (Compro) alongside an injection of sumatriptan (Imitrex) to help relieve pain and nausea.
It also recommends dexamethasone (Decadron) to help prevent another migraine episode.
Alternative medications and remedies
OTC medications like ibuprofen (Advil), acetaminophen (Tylenol), and naproxen (Aleve) can help with migraine management. If you have migraine that keeps coming back, a doctor or healthcare professional might also recommend intravenous dexamethasone.
Many people with migraine also use alternative treatments such as acupuncture.
Biofeedback and relaxation training are also ways to help prevent migraine attacks and reduce symptoms.
Risks and drug interactions
Triptans can increase blood pressure, and medical professionals will typically not prescribe them for people with heart or vascular conditions like hypertension.
You should not take a triptan within 24 hours of taking an alternative triptan or ergot-type medication like dihydroergotamine (D.H.E. 45). Additionally, you should be cautious if you have a liver condition or a specific rare migraine subtype, like hemiplegic migraine or basilar migraine.
D.H.E 45 drug interactions
If you have a cardiovascular condition, a doctor or healthcare professional may recommend avoiding D.H.E. 45 due to the number of possible drug interactions.
They may advise you to avoid D.H.E. 45 if you are taking vasoconstrictors or vasopressors like midodrine (Orvaten) that work to raise your blood pressure or beta-blockers like propranolol (Inderal) that you may take for heart or circulatory conditions.
Nicotine products can also interact with D.H.E 45, causing blood vessels to narrow and potentially restrict the flow of blood and oxygen.
Finally, if you’re taking sumatriptan, wait 24 hours before your D.H.E. 45 dosage.
Summary
Migraine medications might help stop an acute episode or “attack,” but the strongest medications vary by person and migraine type.
Triptans constrict cranial arteries, which widen during a migraine. The right triptan depends on your medical history and the severity and length of your migraine.
Other options to treat migraine include injectable dihydroergotamine, dexamethasone, anti-nausea and antisickness drugs, OTC pain relievers, and alternative therapies.
Consider discussing your symptoms with a doctor or healthcare professional so that you can devise a treatment plan for acute migraine episodes.
Download the free Optum Perks Discount Card to save up to 80% on some prescription medications.