Can painkillers like acetylsalicylic acid or acetaminophen (paracetamol) help?

NSAID painkillers have been shown to effectively relieve migraine pain. The most commonly used painkillers in Germany are acetylsalicylic acid (ASA, used in medicines like Aspirin), diclofenac, ibuprofen and acetaminophen (paracetamol). Research has shown that these drugs are effective in treating migraine:

• Without painkillers, migraine pain disappeared within two hours in about 10 out of 100 people.
• With painkillers, it disappeared within the same time in about 20 out of 100 people.

In other words, the pain was gone in an extra 10 out of 100 people two hours after taking the medicine. Another 20 out of 100 people can expect some pain relief. The effectiveness of a drug will depend on things like the severity of the migraine and the dose used.

Effectiveness of painkillers

The following table shows the doses commonly used to treat migraines in adults:

What are the side effects?

Side effects are rare since painkillers are usually only used for a short time in migraine treatment. In studies, ibuprofen caused stomach ache in less than 1 out of 100 people. Other drugs didn't have any side effects. But taking painkillers may be a problem for people who already have certain conditions, such as kidney damage.

NSAIDs can also affect the stomach lining, so they aren't suitable for people who have stomach ulcers. Acetylsalicylic acid can reduce the blood's ability to clot, increasing the risk of bleeding. Usually the bleeding is slight, for instance a nosebleed or bleeding gums. In rare cases it may be more serious, for example in the gastrointestinal tract. High doses of NSAIDs can also increase the risk of complications in people who have cardiovascular disease.

Acetaminophen (paracetamol) is not suitable for people with impaired liver function because it is broken down in the liver. At high doses it can even cause liver damage in people who are otherwise healthy. So it's important not to exceed the maximum recommended daily dose.

What drugs relieve nausea?

If you feel nauseous during migraine attacks, you can take domperidone or metoclopramide in addition to painkillers. It is estimated that these drugs relieve nausea and vomiting in about 40 out of 100 people. Combination drugs are also available. They combine a painkiller with a drug for nausea relief, for instance acetaminophen (paracetamol) with metoclopramide.

How do migraine medications like triptans and ergotamines work?

Triptans

Triptans were developed specifically for the treatment of migraine. All of the triptans act to narrow the blood vessels in the brain and inhibit the release of chemical messengers that contribute to inflammation. Triptans can relieve pain and help reduce nausea and sensitivity to light. Seven different triptans are currently available in Germany:

• almotriptan
• eletriptan
• frovatriptan
• naratriptan
• rizatriptan
• sumatriptan
• zolmitriptan

Some of these drugs can be used in different forms: tablets, capsules, nasal sprays, suppositories, injection solutions or lozenges that are placed under the tongue. Injections can be given using a pre-filled pen that your doctor can prescribe. Most triptans are prescription-only. Almotriptan and naratriptan are available without a prescription.

Because of chemical differences between the triptans, they are sometimes taken in different doses. For instance, sumatriptan tablets have 50 or 100 mg of sumatriptan in them, whereas zolmitriptan tablets contain 2.5 or 5 mg of zolmitriptan. The different triptans also differ in terms of their duration of action. Some of them start working more quickly and have a shorter effect. This means that if one triptan doesn't provide enough relief, it might be worth trying another.

All triptans can help relieve migraines. Studies on the most commonly prescribed triptan, sumatriptan (50 mg), for example, show the following:

• Without sumatriptan, migraine pain went away within two hours in about 10 out of 100 people.
• With sumatriptan, the pain disappeared in the same time in 20 to 30 out of 100 people.

So an additional 10 to 20 out of 100 people had no pain two hours later. And the drug offered at least some pain relief in another 25 out of 100 people.

Effectiveness of triptans

How quickly and effectively a drug works will also depend on the severity of the migraine, the dose of the drug and how it is administered. For instance, injections are faster and more effective than other forms of administration, but they also have more side effects.

The possible side effects of triptans include drowsiness, unusual sensations such as tingling, weakness, heat or cold, and sometimes mild nausea as well. Using a suppository or injection might help avoid nausea. But triptans aren't suitable for people who have cardiovascular (heart and blood vessel) diseases. This is because triptans can narrow the blood vessels and increase blood pressure, although this is rare.

Which medications are suitable for children and teenagers?

Medications sometimes have different effects in children and teenagers than they do in adults. They need other doses, and some of the side effects are also different. The following medications have been approved in Europe for the treatment of migraines in children and teenagers:

• ibuprofen
• acetaminophen (paracetamol): for children ages 12 and up, also in combination with metoclopramide
• sumatriptan: as a nasal spray for children ages 12 and up

It's not clear whether acetaminophen can relieve migraine symptoms in children and teenagers. Several studies show that ibuprofen can help relieve migraine attacks. There were no serious side effects in the studies involving children with migraines. Mild side effects like stomach ache were rare.

The sumatriptan nasal spray also helped relieve migraine attacks in children and teenagers. Mild side effects were more common though, such as an unpleasant taste or nausea.

Children and teenagers can also be prescribed medication that hasn't been approved for their age group. This is known as "off-label use." If your doctor prescribes a medication off-label, then he or she needs to explain why and tell you about the associated risks.

What can happen if you take painkillers too often?

Painkillers or triptans can themselves cause headaches if used too often. These headaches are known as medication overuse headaches or rebound headaches. Medication overuse headaches cause a dull pain that affects the entire head. Pain from a migraine is more of a throbbing pain, and is accompanied by other symptoms. Medication overuse headaches are chronic, occurring on more than 15 days per month for three months. People with this kind of headache may still have migraine attacks.

If you have medication overuse headaches, it makes sense to stop taking the medication for a while, even if the headache gets worse at first and there are other withdrawal symptoms such as restlessness, trouble sleeping or nausea.

Sources

• Barnes NP. Migraine headache in children. BMJ Clin Evid 2015: pii: 0318.
• Bird S, Derry S, Moore RA. Zolmitriptan for acute migraine attacks in adults. Cochrane Database Syst Rev 2014; (5): CD008616. [PMC free article: PMC6485805] [PubMed: 24848613]
• Damen L, Bruijn JK, Verhagen AP, Berger MY, Passchier J, Koes BW. Symptomatic treatment of migraine in children: a systematic review of medication trials. Pediatrics 2005; 116(2): e295-302. [PubMed: 16061583]
• Derry CJ, Derry S, Moore RA. Sumatriptan (all routes of administration) for acute migraine attacks in adults - overview of Cochrane reviews. Cochrane Database Syst Rev 2014; (5): CD009108. [PMC free article: PMC6469574] [PubMed: 24865446]
• Derry CJ, Derry S, Moore RA. Sumatriptan (oral route of administration) for acute migraine attacks in adults. Cochrane Database Syst Rev 2012; (2): CD008615. [PMC free article: PMC4167868] [PubMed: 22336849]
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• Deutsche Gesellschaft für Neurologie (DGN). Therapie der Migräneattacke und Prophylaxe der Migräne (S1-Leitlinie). AWMF-Registernr.: 030-057. January 2018. (Leitlinien für Diagnostik und Therapie in der Neurologie).
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• Richer L, Billinghurst L, Linsdell MA, Russell K, Vandermeer B, Crumley ET et al. Drugs for the acute treatment of migraine in children and adolescents. Cochrane Database Syst Rev 2016; (4): CD005220. [PMC free article: PMC6516975] [PubMed: 27091010]

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