Migraine Treatment: How to Stop an Attack and How to Prevent the Next One
Migraine treatment has two halves that work on different clocks. Acute treatment stops the attack that is happening now, and it lives or dies by timing. Preventive treatment reduces how often attacks come, and it is judged over months rather than hours. Confusing the two is the most common reason people feel their migraine is untreatable.
There is also a third thing, less discussed and more damaging than either: the treatment that makes migraine worse. Taking acute painkillers too often converts episodic migraine into a daily headache, and it happens to people who are following instructions on a packet.
🌀 The four phases, and why the trigger idea is half wrong
| Phase | Timing | What happens |
|---|---|---|
| Prodrome | Hours to 2 days before | Yawning, neck stiffness, mood change, food cravings, frequent urination, difficulty concentrating |
| Aura | 5 to 60 minutes | Zigzag lines, blind spots, tingling spreading up an arm, speech difficulty. Occurs in about a third of people |
| Headache | 4 to 72 hours | Throbbing, often one-sided, worse with movement, with nausea and sensitivity to light and sound |
| Postdrome | Up to 24 hours | Exhaustion, mental fog, a washed-out feeling people describe as a hangover |
🍫 Chocolate is probably innocent. Food cravings are a prodrome symptom, appearing hours before the pain. People reach for chocolate because the attack has already started in the brain, then blame the chocolate when the headache arrives. The same logic applies to several classic triggers. The ones that do hold up in studies are irregular sleep, skipped meals, dehydration, alcohol, hormonal changes and weather shifts.
⚡ Stopping an attack: the timing rule
Every acute migraine treatment works better the earlier it is taken. As an attack progresses, a process called central sensitisation sets in, the scalp becomes tender to touch, and medicines that would have worked at the start no longer do.
The practical rule: treat at the first clear sign of headache pain. Not during the aura, where triptans are less effective, and not after waiting two hours to see whether this one will be bad.
💊 Triptans, and how to use them properly
Triptans act on serotonin 5-HT1B and 5-HT1D receptors, reducing the release of inflammatory peptides around the trigeminal nerve endings and narrowing dilated cranial vessels. They treat the migraine mechanism rather than masking pain, which is why they also relieve the nausea and light sensitivity.
| Medicine | Dose | Notes |
|---|---|---|
| Imitrex (Sumatriptan 25/50/100 mg) | 50 or 100 mg at onset; may repeat once after 2 hours; maximum 200 mg in 24 hours | The original triptan and the most studied |
| Maxalt (Rizatriptan 5/10 mg) | 10 mg at onset; may repeat once after 2 hours; maximum 30 mg in 24 hours | Faster onset than sumatriptan for many people |
- 🔄 If one triptan does not work, another often does. Response varies between individuals for reasons that are not understood. A triptan should be tried across three separate attacks before it is written off, and then a different one tried
- 🤢 If vomiting starts early, tablets will not be absorbed. An anti-sickness medicine taken alongside helps, and injectable or nasal forms exist for this reason
- 🚫 Do not combine with ergot medicines within 24 hours
⚠️ When triptans must not be used. They constrict blood vessels, so they are contraindicated in coronary artery disease, previous heart attack or stroke, uncontrolled high blood pressure, peripheral vascular disease and severe liver impairment. They are also avoided in hemiplegic migraine and migraine with brainstem aura. Anyone over 40 with cardiovascular risk factors should be assessed before starting one.
💉 What else helps during an attack
Simple analgesics and NSAIDs work for milder attacks, particularly taken early and at a full dose: Naprosyn (Naproxen) or Motrin (Ibuprofen). An NSAID combined with a triptan works better than either alone for attacks that tend to return the next day.
Anti-nausea medicines earn their place twice over: they treat the nausea and they restore gastric emptying, which improves absorption of everything else. A dark quiet room, a cold pack and sleep remain genuinely effective, and sleep ends many attacks outright.
🚨 The headache caused by headache treatment
This is the part most migraine articles leave out, and it explains a large share of daily headache.
Medication overuse headache develops when acute treatment is taken too frequently. The brain adapts, the original headaches become more frequent, and more medicine is needed for less relief. It develops in a substantial proportion of people with chronic daily headache, and it is fully reversible.
| Medicine type | Threshold for overuse |
|---|---|
| Triptans | 10 or more days per month |
| Combination painkillers with codeine or caffeine | 10 or more days per month |
| Opioids | 10 or more days per month |
| Simple painkillers and NSAIDs | 15 or more days per month |
Those thresholds refer to regular use over three months or more. Treatment means stopping the overused medicine, which produces one to two weeks of worse headache before improvement, ideally with a preventive started at the same time. The improvement afterwards is often dramatic.
📓 Keep a headache diary before it becomes a problem. Date, duration, what was taken, and whether it worked. Two months of records answer the two questions that decide treatment: how many headache days a month, and how many days medication was used. Most people underestimate both.
🛡️ Prevention: when it is worth it
Preventive treatment is usually offered when there are four or more migraine days a month, when attacks are severely disabling however often they come, when acute treatment does not work or cannot be used, or when there is a risk of medication overuse.
Two rules govern all preventives:
- Start low and increase slowly. Most side effects come from starting at the target dose
- Give it 8 to 12 weeks at an adequate dose before deciding it has failed. Stopping at three weeks is the usual reason a preventive is wrongly labelled ineffective
Success is defined as roughly halving the number of migraine days, not eliminating them.
| Medicine | Typical dose | Suits | Watch for |
|---|---|---|---|
| Inderal (Propranolol) | 80 to 160 mg daily | Coexisting high blood pressure, anxiety, tremor | Avoided in asthma; fatigue, cold hands, vivid dreams |
| Elavil (Amitriptyline) | 10 to 50 mg at night | Coexisting insomnia, tension headache, chronic pain | Drowsiness, dry mouth, weight gain |
| Topamax (Topiramate) | 25 mg, building to 50 to 100 mg daily | Migraine with obesity; strong evidence base | Tingling in hands and feet, word-finding difficulty, kidney stones |
| Depakote (Divalproex) | 500 to 1000 mg daily | Migraine with epilepsy | Weight gain, tremor, liver effects |
| Sibelium (Flunarizine) | 5 to 10 mg at night | Migraine with vertigo or vestibular symptoms | Weight gain, drowsiness, low mood; avoided in older adults |
🤰 Two preventives that require contraception discussions first. Divalproex causes neural tube defects and reduced cognitive development, and it is not used in women who could become pregnant unless no alternative exists and a pregnancy prevention programme is in place. Topiramate carries a risk of cleft lip and palate, and at doses above 200 mg daily it can reduce the effectiveness of combined oral contraceptives. Neither should be started without that conversation.
Beyond these, candesartan has good evidence as a preventive and is available here as Atacand (Candesartan). The newer CGRP monoclonal antibodies and gepants are the biggest recent advance in migraine prevention and are not part of our catalogue.
🌿 Supplements with real trial evidence
- Riboflavin, 400 mg daily
- Reduces attack frequency in trials, with effect appearing after about three months. It turns urine bright yellow, which is harmless. Cheap and well tolerated.
- Magnesium, 400 to 600 mg daily
- Modest benefit, better supported in migraine with aura and in menstrual migraine. Loose stools are the limiting side effect, reduced by using the citrate or glycinate form.
- Coenzyme Q10, 300 mg daily
- Reduces frequency in small trials. Expensive relative to the effect but safe.
These do not match prescription preventives for effect. They suit people with fewer attacks, those wanting to try something before medication, and pregnancy, where most preventives are avoided.
🌸 Menstrual migraine and the contraceptive question
Attacks clustered from two days before a period to three days into it are driven by the fall in oestrogen rather than by the period itself. They tend to be longer, more severe and less responsive to triptans than other attacks.
Short preventive courses taken around the expected dates work well: an NSAID such as naproxen twice daily, or a longer-acting triptan, started two days before and continued through the vulnerable window.
⚠️ Migraine with aura and combined contraceptives. Migraine with aura roughly doubles the background risk of ischaemic stroke, and combined hormonal contraceptives multiply that further. For that reason combined pills are generally avoided in women who have migraine with aura. Progestogen-only methods and non-hormonal options are not affected by this restriction. Anyone with aura using a combined pill should discuss it with a doctor rather than stop abruptly. Our birth control category lists the available options.
🚨 Headaches that are not migraine
Most headaches are benign. A short list is not, and these need assessment rather than treatment:
- Thunderclap headache reaching maximum intensity within a minute — emergency, possible bleed
- Headache with fever, neck stiffness or a rash
- Headache with weakness, speech difficulty, confusion or a seizure
- A new headache after the age of 50, particularly with scalp tenderness or jaw pain on chewing, which suggests giant cell arteritis
- Headache worse when lying down, coughing or straining, or waking you from sleep
- A clear change in a familiar headache pattern, or steady worsening over weeks
- Aura lasting more than an hour, or always affecting the same side
- Headache after a head injury
❓ Frequently asked questions
When should I take a triptan?
At the first clear sign of headache pain, not during the aura and not after waiting to see how bad it gets. Once the attack has progressed and the scalp becomes tender, triptans work much less well.
What is the dose of sumatriptan?
Fifty or 100 mg at the onset of headache, repeatable once after two hours if the headache returns, with a maximum of 200 mg in 24 hours. A second dose does not help if the first had no effect at all.
The triptan did not work. Is that it?
No. Response varies between individuals and a different triptan often works when one does not. Each should be tried over three separate attacks before moving on, and combining it with an NSAID improves results for attacks that recur the next day.
Who should not take triptans?
People with coronary artery disease, previous heart attack or stroke, uncontrolled high blood pressure or peripheral vascular disease, and those with hemiplegic migraine or migraine with brainstem aura, because triptans narrow blood vessels.
Can painkillers make headaches worse?
Yes. Triptans, opioids and combination painkillers taken on 10 or more days a month, or simple painkillers on 15 or more, can cause medication overuse headache. Stopping the overused medicine reverses it, usually after one to two difficult weeks.
When should I start preventive medication?
Usually at four or more migraine days a month, or when attacks are severely disabling however often they come, or when acute treatment fails or is being used too often.
How long before a preventive works?
Eight to twelve weeks at an adequate dose. Stopping after three weeks is the main reason a preventive is wrongly judged ineffective. Success means roughly halving the number of migraine days, not eliminating them.
Does chocolate trigger migraines?
Probably not. Food cravings are a prodrome symptom that appears hours before the pain, so the attack has already begun when the chocolate is eaten. Irregular sleep, skipped meals, dehydration, alcohol and hormonal changes hold up better as genuine triggers.
Can I take the combined pill if I have migraine with aura?
Generally no. Migraine with aura raises stroke risk and combined hormonal contraceptives raise it further, so they are usually avoided. Progestogen-only and non-hormonal methods are not affected. Discuss it with a doctor rather than stopping abruptly.
Which headaches need urgent assessment?
A thunderclap headache peaking within a minute, headache with fever or neck stiffness, headache with weakness or speech difficulty, a new headache after 50, one that worsens lying down or wakes you from sleep, or a clear change in a long-standing pattern.
📑 Sources and editorial
- International Classification of Headache Disorders criteria for migraine and medication overuse headache
- Neurology guidelines on acute and preventive migraine treatment
- Prescribing information for sumatriptan, rizatriptan, propranolol, amitriptyline, topiramate, divalproex and flunarizine
- Trials of riboflavin, magnesium and coenzyme Q10 in migraine prevention
- Studies of stroke risk in migraine with aura and combined hormonal contraceptive use
- Related products: Imitrex (Sumatriptan), Maxalt (Rizatriptan), Sibelium (Flunarizine), Inderal (Propranolol), migraine category
- RXshop Editorial Team — reviewed by Daniel Kim, MD, Endocrinology
Medical Disclaimer: The information in this article is for educational and informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek guidance from a qualified healthcare provider with any questions you may have regarding a medical condition, and before starting, stopping or changing any medication.