Simple analgesics:

• Acetaminophen (Tylenol)

• NSAIDs (ibuprofen, naproxen, diclofenac)

Migraine-specific medications:

• Triptans (almotriptan, eletriptan, frovatriptan, naratriptan, sumatriptan, zolmitriptan)

• Gepants (ubrogepant, rimegepant)

Other:

• Ergotamines or ergots used to be commonly used, but have fallen out of favour due to lower tolerability

• Metoclopramide is a commonly prescribed adjunct that can alleviate migraine pain and nausea

Often acetaminophen or an NSAID taken early are effective.

Many people benefit from a triptan or a gepant, especially when taken early. 

Triptans act on serotonin receptors in the brain. This helps:

• Calm overactive migraine pain pathways

• Reduce migraine-related inflammation

• Restore normal nerve signalling

They are migraine-specific medications rather than general painkillers.

No.

Although triptans work on serotonin receptors, they are different than the serotonin receptors involved in serotonin syndrome. They are safe to take even if you take other medications that act on serotonin receptors.

Migraine can be thought of as a fire: when it is small it is easier to put out compared to when it is roaring.

Early in an attack, the migraine pain system is easier to interrupt.

Once migraine pain becomes severe, the nervous system is more sensitized and triptans are less effective.

Gepants block CGRP (calcitonin gene–related peptide), a neuropeptide involved in migraine. 

• They do not constrict blood vessels

• They may be safer for people with vascular or coronary artery disease

• They are less likely to cause medication-overuse headache

• They may be better tolerated

• Studies show that for most people triptans may be more effective, while gepants may be better tolerated. Everybody is different, and it is difficult to predict which medication will work best for you.

As early as possible, once migraine pain begins.

• A triptan should be tried for at least 3 separate migraine attacks before deciding whether it is effective.

• Response can vary depending on timing, severity, and formulation.

• If one triptan doesn't work, a different one can be trialed.

• Many triptans can be repeated once after 2 hours

• Some gepants (i.e., ubrogepant) allow a second dose once after 2 hours

Often, yes. A common effective approach (when appropriate) is:

• Triptan + NSAID

• Add an anti-nausea medication if needed

• Avoid taking two different triptans on the same day unless instructed.

When combining medications it is still important to stay under the monthly medication use limits given by your doctor.

Yes. Common and usually harmless sensations include:

• Warmth or flushing

• Tightness in the neck, jaw, or chest

• Tingling or pins-and-needles

• Mild dizziness or sleepiness

These usually pass within 30–60 minutes.
Seek medical attention if chest pain is severe, prolonged, or different from previous reactions.

Yes. Mild fatigue, nausea, or dry mouth can occur. 

Using acute medication too frequently can cause medication-overuse headache.

Medication-overuse headache can be disabling and its treatment is focused on getting rid of the culprit medication. This can be difficulty since people are relying on the acute medication in the first place to cope with their migraine attacks. For this reason, it is best to prevent medication-overuse headache altogether by staying under the monthly acute medication use limits.

• Simple analgesics (Acetaminophen / NSAIDs): aim for ≤14 days per month

• Triptans: aim for ≤9 days per month

• Opioids/narcotics: should be avoided for headache

• Gepants: follow your doctor's recommendation. Gepants are typically not thought to cause medication-overuse headache.

Current evidence suggests gepants are unlikely to cause medication-overuse headache. 

Options include:

• Anti-nausea medications (e.g., metoclopramide)

• Nasal or injectable triptans

• Treating migraine attacks early before severe nausea/vomiting kicks in

• Dark, quiet environment

• Cold pack on head or neck

• Hydration

• Relaxation breathing or mindfulness

• Neuromodulation devices

• Non-medication strategies first

• Acetaminophen is first-line

• NSAIDs only in limited situations (avoid in third trimester)

• Sumatriptan is the best-studied triptan in pregnancy and may be used when needed

• Avoid gepants in pregnancy

• Craniofacial nerve blocks (e.g. occipital nerve blocks) are a safe option in pregnancy

We can help you decide on the acute strategies that are right for you.

Most migraine medications are compatible with breastfeeding and lactation.

Of the triptans, sumatriptan and eletriptan carry the most evidence for use.

Gepants have yet to be proven safe in breastfeeding and lactation, although some specialists prescribe them with caution. We can help you choose and time doses safely. 

1. Ensure treating early and with an effective dose

2. Try a different formulation (nasal or injection)

3. Switch to another triptan or to a gepant

4. Use combination therapy when appropriate

5. Consider preventive treatment

Consider prevention if you have:

• 4 or more migraine attacks per month

• Highly disabling attacks

• Frequent acute medication use

• Acute medications are ineffective

• Chronic migraine (headache for more than half of the month, and migraine for more than a quarter of the month)

Migraine is a chronic condition that is marked by flares or attacks.

The goals of preventive medications are to:

• Reduce the frequency of attacks

• Reduce the severity or intensity of the attacks

• Reduce the duration of attacks

• Make the migraine attacks more vulnerable to acute medications (i.e., easier to treat)

These medications are not effective "as needed".

There are many non-specific oral preventive medications that can be used to prevent migraine. Among them, some of the more common ones include:

• Amitriptyline / Nortriptyline

• Candesartan

• Metoprolol or propranolol

• Topiramate

To reduce side effects and allow the body to adjust.

Usually 8 weeks at a therapeutic dose.

Most insurer providers request a minimum trial of 3 months before approving coverage for migraine-specific preventive medications.

CGRP (calcitonin gene-related peptide) is a naturally neuropeptide protein involved in:

• Pain transmission

• Sensitization of migraine pathways

• Migraine attack generation

• Vasodilation

During migraine attacks, CGRP levels increase and contribute to headache pain and associated symptoms.

They block CGRP or its receptor, reducing baseline migraine sensitivity and preventing attacks before they start. 

Monthly subcutaneous auto-injection (erenumab, galcanezumab)

Monthly or every 3 months subcutaneous auto-injection (fremanezumab)

IV infusion every 3 months (eptinezumab)

They do not suppress the immune system and do not meaningfully increase infection risk.

Studies have found a small signal that some people may be at a higher risk of urinary tract infections or nasopharyngeal infections.

Yes. Vaccinations are safe while on CGRP therapy. 

They remain in the body for a long time and are not studied in pregnancy.

They should be stopped at least 6 months before conception. 

Atogepant blocks CGRP daily, preventing migraine from starting.

It works quickly and clears quickly if stopped. 

Botox ® injected using a validated migraine protocol prevents release of migraine-related chemicals (including CGRP) and reduces the brain's sensitization to headache.

Every 12 weeks. 

No. Botox ® acts locally and does not affect immune function. 

While Botox ® is not formally recommended by guidelines in pregnancy, many headache specialists are comfortable using it in pregnancy. This is informed by large registry studies showing safety.

Our specialist can help you make an informed decision.

Yes.

While many patients only need a CGRP antagonist or Botox ®, others remain on a oral preventive alongside CGRP therapy or Botox ®. 

Yes. Some nutraceuticals (vitamins and supplements) have evidence for migraine prevention and are commonly recommended, especially for people who:

• Prefer non-prescription options

• Have mild to moderate migraine

• Want to add something low-risk to prescription prevention

• Are pregnant or planning pregnancy (some options are safer)

Options include:

• Magnesium 400-600 mg orally daily

• Riboflavin (Vitamin B2) 400 mg orally daily

• Coenzyme Q10 (CoQ10) 200-300 mg orally daily

These supplements work gradually and usually take 8–12 weeks to show benefit.

Migraine that predictably occurs around menstruation due to estrogen changes.

Short-term preventive treatment used only during the high-risk menstrual window. 

Depending on the person:

• NSAIDs (e.g., naproxen)

• Triptans taken daily during the window, generally started 2-3 days before menses (e.g., frovatriptan, which is a long-acting triptan

• Gepants

1. Prodrome – early warning symptoms (fatigue, neck stiffness, cravings)

2. Aura (in some people) – visual or sensory symptoms

3. Headache phase – pain, nausea, light and sound sensitivity

4. Postdrome (migraine hangover) – lingering symptoms after pain improves

Neck pain is a common symptom during the migraine prodrome. For most people, it typically suggests that they are already in a migraine attack.

A phase after headache pain resolves, marked by:

• Fatigue or exhaustion

• Brain fog or slowed thinking

• Low mood or irritability

• Residual head or neck discomfort

This can last hours to a full day or longer.

Yes. The migraine hangover is a normal part of the migraine process. 

• Rest and hydration

• Gentle activity

• Sleep

• Avoid overusing pain medication

Usually no.

The vast majority of patients with migraine do not need any brain imaging. Migraine is diagnosed clinically. 

Currently, most plans use step therapy with pre-authorization criteria.

Each insurance plan is different.

A headache diary helps identify patterns, triggers, and how well treatments work. It’s also valuable when talking with your clinician about preventive therapy. 

• Trial of at least two oral preventive medications

• Each at a therapeutic dose for ~3 months (varies by insurance)

• Documentation of migraine frequency and impact

Coverage varies by insurer.

Not always. Once stable, care can usually transition to your family doctor and they should continue any relevant renewals.

Yes. Once established:

• No routine bloodwork or monitoring is required

• GP renewal is safe and appropriate

• Renewal is easier now with less paper-work and support programs are available to help family doctors with renewals.

If migraine worsens, side effects occur, pregnancy is planned, or treatment changes are needed. 

Yes.

With the right acute and preventive strategy, most people experience fewer attacks, less disability, and better daily function.