Chronic migraines aren’t just bad headaches. They’re debilitating neurological events that can knock you out for hours-or days. If you’re one of the 39 million Americans or 1 billion people worldwide who live with them, you know the struggle: the pounding pain, the nausea, the light and sound sensitivity, the fear of the next attack. And if you’ve tried over-the-counter painkillers that barely help, you’re not alone. The truth is, most people with migraines aren’t getting the right treatment. Too many still end up with narcotics or nothing at all, while proven, targeted therapies sit unused. This isn’t about luck. It’s about matching the right medication to your type of migraine-and doing it at the right time.
Abortive Medications: Stopping a Migraine in Its Tracks
Abortive meds are your emergency toolkit. They don’t prevent attacks-they stop them once they’ve started. And timing matters. The sooner you take them after the first sign-whether it’s aura, neck stiffness, or the first throb-the better they work. Studies show taking treatment within one hour of onset cuts recurrence rates in half.
First-line options are simple and cheap: NSAIDs like ibuprofen (400mg), naproxen (550mg), or aspirin (900-1000mg). These work for mild to moderate migraines by blocking inflammation. The combo of acetaminophen, aspirin, and caffeine (Excedrin Migraine) has solid data behind it, especially when taken early. But here’s the catch: if you’re vomiting or your stomach’s shut down-which happens in most moderate attacks-oral pills may not absorb. That’s where nasal sprays, injections, or suppositories come in.
For moderate to severe migraines, triptans are the gold standard. Sumatriptan, rizatriptan, and zolmitriptan work by narrowing blood vessels and calming overactive nerves. They’re effective in 42-76% of cases at relieving pain within two hours. But they’re not for everyone. If you have heart disease, high blood pressure, or a history of stroke, triptans can be risky. And they don’t work for everyone-even if you take them perfectly.
That’s where the new generation comes in. CGRP receptor antagonists like ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT) block a key migraine-triggering chemical without affecting blood vessels. That means they’re safe for people who can’t take triptans. Rimegepant, taken as a dissolving tablet, often works in under 30 minutes. In one study, 21% of users were pain-free at two hours-compared to 10% on placebo. And unlike triptans, you can use them more than 10 times a month without triggering medication-overuse headaches.
Then there’s lasmiditan (Reyvow), a serotonin 5-HT1F agonist. It doesn’t constrict blood vessels at all, making it ideal for high-risk patients. It’s not a magic bullet-dizziness is common-but for those who’ve tried everything else, it works. One meta-analysis found it was 56% more effective than placebo at reducing pain in two hours.
And now, in late 2023, the FDA approved zavegepant (Zavzpret), a nasal spray version of a CGRP blocker. It’s fast, non-invasive, and works even if you can’t swallow pills. In trials, 24% of users were pain-free at two hours. That’s a big deal for people who’ve struggled with absorption or hate injections.
Preventive Medications: Reducing the Frequency Before It Starts
If you’re having 4 or more migraine days a month, or if abortive meds aren’t cutting it, it’s time to think about prevention. These aren’t pills you take when you feel a headache coming. They’re daily meds that lower your overall sensitivity to triggers.
For years, the go-to options were old-school drugs repurposed from other conditions: beta-blockers like propranolol or metoprolol, anticonvulsants like topiramate or valproate, and antidepressants like amitriptyline. They work for many-but side effects can be rough. Topiramate can cause brain fog and tingling. Amitriptyline makes you drowsy. Propranolol can lower your energy too much.
The real game-changer came with CGRP monoclonal antibodies. These are monthly or quarterly injections that block the migraine-triggering protein at its source. Erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality) are FDA-approved and backed by level A evidence from the American Academy of Neurology. In trials, they cut migraine days by 50% or more in about half of users. And side effects? Mostly just injection-site soreness. No liver toxicity. No brain fog. No weight gain.
For women with menstrual migraines, long-acting triptans like frovatriptan or naratriptan, taken a few days before and during your period, can be lifesaving. You don’t need to take them every day-just around your cycle.
And now, atogepant (Qulipta) is approved as the first daily oral CGRP blocker for prevention. It’s taken once a day and has shown strong results in reducing migraine days without the sedation of older drugs. Phase 3 data for episodic migraine is expected in late 2024, and early results look promising.
What Doesn’t Work-and Why It’s Still Prescribed
Here’s the uncomfortable truth: 15% of migraine patients still get narcotics like oxycodone or hydrocodone for acute attacks. That’s not because they’re effective. It’s because doctors don’t know better-or they’re running out of time. Narcotics don’t stop migraines. They just numb them. And they carry a high risk of dependence and medication-overuse headaches. The American Headache Society has been clear: avoid opioids. Yet they’re still handed out.
Another problem? Underuse of combination therapy. Taking a triptan with an NSAID like naproxen gives better results than either alone. One study showed 32% pain-free rates with the combo versus 22% with triptan alone. But most patients aren’t told this. They’re given one pill and sent on their way.
And cost? That’s a huge barrier. A 6-pill pack of ubrogepant can cost over $900 out-of-pocket. Even with insurance, many plans require you to fail three other drugs first. That’s called step therapy-and it’s holding back progress. Only 12.6% of migraine sufferers are getting guideline-recommended acute care. That’s not just a gap. It’s a crisis.
Real-World Tips: What Patients Actually Do
People who manage migraines well don’t just rely on pills. They combine meds with habits.
- Take your abortive med with water-and if you’re nauseous, use a suppository like metoclopramide or ondansetron. Migraines slow your stomach down. Pills sit there and don’t get absorbed.
- Use ice packs on your neck or forehead. Cold reduces inflammation and nerve firing.
- Stay in a dark, quiet room. Even if you’re tempted to check your phone, don’t. Light and sound can prolong the attack.
- Keep a headache diary. Tracking triggers (sleep, stress, weather, food) helps you avoid them. Studies show consistent logging for 8 weeks improves trigger identification by 70%.
- Don’t overuse abortive meds. Triptans can cause rebound headaches after 10 doses a month. NSAIDs after 15. Keep a log.
On Reddit’s r/Migraine community, 68% of 1,200+ respondents said triptans were their most effective tool. But 22% said NSAIDs were enough. And 10% said the new CGRP drugs were a revelation-especially because they didn’t cause heart palpitations or dizziness like triptans did.
Where the Field Is Headed
The migraine treatment market is exploding. It’s expected to hit $10.8 billion by 2030, mostly because of CGRP drugs. In 2024, the American Headache Society is updating its guidelines to put rimegepant and lasmiditan at the top of the abortive list for people who can’t use triptans. That’s huge-it means these drugs are no longer last-resort options.
Future drugs are coming fast. Oral CGRP blockers like atogepant are being tested for episodic migraine. New 5-HT1F agonists are in early trials. And researchers are starting to look at genetic markers to predict who responds to which drug. The goal? Personalized treatment: one pill for you, not a one-size-fits-all approach.
But until then, the best thing you can do is get informed. Talk to a headache specialist-not just your GP. Ask about CGRP inhibitors. Ask about combination therapy. Ask about alternatives if triptans don’t work or aren’t safe for you. And if your doctor pushes opioids, push back. There are better options. You deserve them.
