Doctors prescribe migraine medications in two broad categories: drugs that stop an attack once it starts, and drugs that reduce how often attacks happen. Most people begin with an acute treatment, and if migraines occur frequently (typically four or more days per month), a preventive medication gets added. The specific prescription depends on how severe your attacks are, how often they happen, and whether you have other health conditions that rule certain options out.
Triptans: The Standard Acute Treatment
Triptans remain the first-line prescription for stopping a migraine in progress. They work by changing blood circulation in the brain and altering how the brain processes pain signals. There are seven triptans available, and they come in different forms depending on what works best for you. Sumatriptan is the most widely prescribed and comes as a pill, nasal spray, or injection. Rizatriptan dissolves on the tongue, which is useful if nausea makes swallowing a pill difficult. Zolmitriptan is available as both a pill and nasal spray. The others (almotriptan, eletriptan, frovatriptan, and naratriptan) are all oral tablets.
Each triptan has a slightly different speed and duration. Frovatriptan, for example, works more slowly but lasts longer, which makes it a common choice for menstrual migraines that persist over several days. Eletriptan tends to be one of the more potent options. If one triptan doesn’t help, it’s worth trying a different one, since people respond to them differently.
Triptans narrow blood vessels, so they’re not prescribed for people with heart disease, uncontrolled high blood pressure, or a history of stroke. Your doctor will ask about cardiovascular risk factors before writing this prescription.
Newer Acute Options: Gepants and Ditans
For people who can’t take triptans or don’t respond well to them, two newer drug classes offer alternatives. Gepants (ubrogepant and rimegepant) block a protein called CGRP that plays a central role in migraine pain. They don’t constrict blood vessels the way triptans do, which makes them safe for people with cardiovascular concerns. Rimegepant has the added benefit of working as both an acute and preventive treatment.
Lasmiditan is the only approved ditan. It targets a different serotonin receptor than triptans and also avoids the blood vessel narrowing issue. The tradeoff is that it can cause significant dizziness and sedation, so you can’t drive for at least eight hours after taking it. Head-to-head comparisons suggest triptans are still more effective overall than these newer options, but gepants and ditans fill an important gap for patients who need a different approach.
Over-the-Counter Pain Relievers With a Caveat
Doctors often recommend over-the-counter anti-inflammatory drugs like ibuprofen or naproxen as a first step for mild to moderate migraines, and sometimes prescribe them at higher doses. Combination products containing acetaminophen, aspirin, and caffeine can also be effective for less severe attacks.
The important limit here is frequency. Using simple painkillers more than 15 days a month, or triptans and combination painkillers more than 9 days a month, can cause medication overuse headache. This is a cycle where the pain reliever itself starts triggering more headaches. If you’re reaching for acute medication more than twice a week, that’s generally the signal to talk about adding a preventive treatment.
Preventive Medications Taken Daily
When migraines are frequent or disabling enough to affect your daily life, doctors prescribe a daily medication to reduce how many attacks you get. These typically cut migraine frequency by about half, and it can take several weeks to see the full effect. The main categories are blood pressure medications, anti-seizure drugs, and antidepressants, all of which happen to have migraine-preventing properties unrelated to their original purpose.
Propranolol, a beta-blocker, is one of the most established options. Topiramate, an anti-seizure medication, is another common choice, though it can cause tingling in the hands, cognitive fogginess, and weight loss. Amitriptyline, a tricyclic antidepressant taken at low doses before bed, works particularly well for people whose migraines overlap with tension headaches or poor sleep. Doctors usually start at the lowest effective dose and increase gradually to minimize side effects.
Finding the right preventive medication often takes trial and error. If the first one doesn’t help after a fair trial of two to three months, switching to a different class is standard practice.
CGRP Inhibitors: Targeted Prevention
A newer generation of preventive treatments specifically targets CGRP, the same migraine-related protein that gepants block. Four injectable CGRP inhibitors are currently available: erenumab, fremanezumab, galcanezumab, and eptinezumab. The first three are self-administered injections you give yourself at home once a month using a prefilled pen similar to an insulin device. Fremanezumab also has a quarterly dosing option (four injections per year). Eptinezumab is the exception: it’s given as an IV infusion at a medical office every three months.
These medications were designed specifically for migraine, which means they tend to have fewer unrelated side effects than repurposed blood pressure or seizure drugs. The most common side effects are injection site reactions and constipation. They typically start working within the first month, faster than many traditional preventives.
Insurance coverage for CGRP inhibitors has improved over time. Some plans previously required patients to try and fail two or three older preventive medications before approving a CGRP inhibitor, though these step therapy requirements have been loosened or removed by some insurers. It’s worth checking with your plan, since coverage policies vary widely.
Botox for Chronic Migraine
Botulinum toxin injections are FDA-approved specifically for chronic migraine, defined as 15 or more headache days per month. The treatment involves multiple small injections across the forehead, temples, and the back of the head and neck. Some specialists also target specific “trigger points” where your headache pain tends to originate. Treatments are repeated roughly every 12 weeks, and many people need two or three rounds before they can tell whether it’s working.
Botox isn’t typically prescribed for people who have fewer than 15 headache days per month. For those who qualify, it can significantly reduce both the number of migraine days and the severity of the attacks that do break through.
Rescue Treatments for Severe Attacks
When standard triptans aren’t enough, doctors sometimes prescribe dihydroergotamine (DHE) for particularly severe or prolonged migraines. It’s available as an injection (given under the skin, into muscle, or intravenously) and as a nasal spray. DHE is an older medication derived from ergot alkaloids, and it’s often used in emergency or infusion center settings for migraines that have lasted days and haven’t responded to other treatments.
Like triptans, DHE narrows blood vessels, so it’s off-limits for people with heart disease, peripheral artery disease, uncontrolled high blood pressure, or severe liver or kidney problems. It also can’t be combined with triptans on the same day or used for certain migraine subtypes that involve weakness or balance problems.
How Doctors Choose Between Options
The prescription you get depends on several factors working together. For someone with occasional migraines and no cardiovascular issues, a triptan is the typical starting point. If migraines happen more than four times a month, a daily preventive like propranolol or topiramate gets added. If those don’t work well enough or cause bothersome side effects, CGRP inhibitors become the next step. People with heart disease or stroke risk factors are steered toward gepants instead of triptans for acute attacks.
Pregnancy adds another layer of complexity. Triptans have not been associated with increased risks for premature birth or birth defects in large studies, but doctors still weigh the decision carefully. DHE is generally avoided during pregnancy due to its effects on blood flow to the uterus, even though recent data suggests the risks may be lower than previously thought. Most specialists work with patients to find the safest possible approach, which sometimes means relying more heavily on non-medication strategies during pregnancy.
Many people end up with a combination approach: a preventive medication to reduce frequency, an acute treatment to stop breakthrough attacks, and awareness of how many days per month they’re using acute medication to avoid the rebound headache cycle.