Stopping the Attack: Acute Treatment Strategies

When a migraine attack begins, the goal of acute treatment is to stop the pain and associated symptoms quickly, allowing you to return to your normal life. Experts recommend a “stratified” approach, where the choice of medication is matched to the severity of your typical attacks ^[1][2].

The Treatment Ladder

Most doctors suggest a step-wise approach based on how much the migraine interferes with your functioning ^[1].

• Mild to Moderate Attacks: Non-specific pain relievers are often the first line of defense. These include NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) like ibuprofen or naproxen, acetaminophen, or combinations containing aspirin and caffeine ^[1][3].
• Moderate to Severe Attacks: If simpler analgesics don’t work, or if your attacks are usually severe from the start, “migraine-specific” medications are used ^[1]. If severe nausea or vomiting occurs, you may consider non-oral options like nasal sprays or injections.

⚠️ OTC Safe-Use Box: Over-the-counter drugs require care. Check with a pharmacist or clinician first:

• NSAIDs: Can cause gastrointestinal bleeding, kidney injury, and blood pressure problems. May be inappropriate if you take anticoagulants, have ulcers, kidney disease, or are in late pregnancy.
• Acetaminophen: Carries liver toxicity risks if daily limits are exceeded or combined with alcohol.
• Aspirin/Caffeine: Frequent use can lead to caffeine withdrawal headaches.

Triptans: The Standard for Severe Pain

Triptans (such as sumatriptan, rizatriptan, and eletriptan) have been the gold standard for stopping moderate-to-severe migraine attacks for decades ^[4]. They work by stimulating serotonin receptors to stop the release of pain-causing chemicals and calm the overactive trigeminal nerve ^[5].

The Cardiovascular Limitation: Triptans cause a slight narrowing (vasoconstriction) of blood vessels ^[4]. For this reason, they are generally contraindicated (should not be used) in people with certain health histories ^[6][7]:

• Established coronary artery disease or a history of heart attack.
• Prior stroke or “mini-stroke” (TIA).
• Peripheral vascular disease.
• Poorly controlled high blood pressure (hypertension).

Newer Alternatives: Gepants and Ditans

For those who cannot take triptans due to heart health concerns, or for those whom triptans simply do not work, newer classes of drugs offer different pathways to relief ^[8].

• Gepants (CGRP Receptor Antagonists): Medications like ubrogepant and rimegepant block the CGRP protein (the “pain messenger”) without narrowing blood vessels ^[8][9]. While considered safer for many people with cardiovascular risk factors, they are not universally “safe.” They have hepatic/CYP drug interactions that require individualized review ^[10].
• Ditans (Lasmiditan): This is a selective serotonin (5-HT1F) agonist. Like gepants, it does not cause blood vessel constriction ^[11]. However, it can cause significant dizziness and sleepiness; FDA guidelines require that you do not drive or operate machinery for at least 8 hours after taking a dose ^[12].

The “Rebound” Risk: Medication Overuse Headache (MOH)

One of the most frustrating aspects of migraine management is that the very medications used to stop an attack can cause more headaches if used too frequently. This is called Medication Overuse Headache (MOH) ^[13]. MOH can occur with any pre-existing headache disorder.

Under the ICHD-3 diagnostic rules, MOH is defined as a headache occurring 15 or more days per month in a person who already has a headache disorder, developing after at least three months of regular “overuse” of acute drugs ^[13][14].

Important Risk Thresholds (These are upper risk limits, not “safe limits”):

• Limit Simple Analgesics: Using NSAIDs or acetaminophen on 15 or more days per month increases MOH risk ^[13].
• Limit Migraine-Specific Drugs: Using triptans or combination pills on 10 or more days per month increases MOH risk ^[13][15].
• Opioids and Butalbital: Routine use is strongly discouraged due to dependence and rapid MOH risk.
• The Gepant Exception: Early, limited evidence suggests that gepants may have a lower risk of causing MOH, though they should still be used under clinical guidance ^[16][17].

If you find you need acute medication more than two days a week, it is often a sign that your brain needs a preventive treatment to lower the number of attacks you have in the first place ^[18].