1 Aspirin

2 Acetaminophen

3 Domperidone

4 Metoclopramide 5 Naproxen 6 Ibuprofen Specific acute migraine attack treatments

When simple measures fail or more aggressive treatment is required, the specific treatments are required. While ergotamine remains a useful antimigraine compound, it can no longer be considered the treatment of choice in acute migraine.60 There are particular situations in which ergotamine is very useful, but its use must be strictly controlled as ergotamine overuse produces dreadful headache, in addition to a host of vascular problems. The triptans have revolutionized the life of many patients with migraine and are clearly the most powerful option available to stop a migraine attack. Triptans

Triptans, 5HT1B/1D receptor agonists, e.g., sumatriptan 7, etc. deserve special mention since their well-described pharmacology allows one to begin to piece together both their antimigraine effect and, by inference, some aspects of migraine pathophysiology. Triptans are extremely effective acute attack treatments for migraine.61 These compounds can potentially reverse each of the components of trigeminovascular activation, viz., constrict large cranial vessels, inhibit peripheral trigeminal terminals, and inhibit activity in the trigeminocervical complex. This effect is reflected in inhibition of release of calcitonin gene-related peptide (CGRP), that is elevated in migraine,62 although as a generic biomarker for clinical trials it may not be useful. This mechanism of action led to the development of highly potent CGRP receptor antagonists,63 and the demonstration in a recent clinical trial that the CGRP receptor antagonist BIBN-4096 8 is effective in acute antimigraine. At the primary end-point of 2 h, 66% of patients had a headache response while 27% of patients had responded to placebo.64

Although the pharmacology of the triptans is very similar, individual patient responses can be remarkably different. Clinical areas where particular triptans are useful are listed in Table 4.

7 Sumatriptan

BIBN-4096 8 Olcegepant

The Prevention and Treatment of Headaches

The Prevention and Treatment of Headaches

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