|  | Conditions & Treatments | Headaches

Headache Medications Guide: OTC Options, Prescription Drugs (Triptans, Ergot, Opioids), and Preventives

Over-the-Counter (OTC) Acute Treatments

  • Acetaminophen (Tylenol): 500-1000 mg q6h; max 3-4 g/day. First-line for mild-moderate; safe in pregnancy.
  • NSAIDs: Ibuprofen 400-600 mg q6h; Naproxen 500 mg q12h. Anti-inflammatory; avoid in GI bleed risk, CKD, CVD.
  • Aspirin: 650-1000 mg; avoid <19 yrs (Reye's), anticoagulated patients.
  • Combination (Excedrin): Acetaminophen 250 + Aspirin 250 + Caffeine 65 mg.

Prescription Acute Migraine Therapies

Triptans (5-HT1B/1D agonists) — First-line for moderate-severe migraine

  • Sumatriptan (oral, nasal, SC), Rizatriptan (ODT), Zolmitriptan, Eletriptan, Almotriptan, Frovatriptan (long half-life), Naratriptan.
  • Contraindicated: CAD, stroke, uncontrolled HTN, hemiplegic/basilar migraine.

Ditans (5-HT1F agonist)

  • Lasmiditan — no vasoconstriction; safe in CVD; causes drowsiness/dizziness.

Gepants (CGRP antagonists)

  • Ubrogepant, Rimegepant (also preventive), Zavegepant (nasal).
  • No vascular contraindications.

Ergot Derivatives

  • Dihydroergotamine (DHE) nasal/IV/IM; Ergotamine/caffeine (Cafergot).
  • More side effects; avoid with triptans (24-hr gap).

Other Acute/Rescue Options

  • NSAIDs (IV/IM): Ketorolac, Diclofenac.
  • Antiemetics: Metoclopramide, Prochlorperazine (also help migraine).
  • Opioids: Avoid if possible (MOH risk, dependence); Butorphanol nasal, Meperidine — last resort.
  • Corticosteroids: Dexamethasone IV for status migrainosus.

Preventive Medications (Daily)

First-line (Guideline-recommended)

  • Beta-blockers: Propranolol, Metoprolol, Timolol.
  • Anticonvulsants: Topiramate, Valproate (avoid pregnancy).
  • Antidepressants: Amitriptyline, Nortriptyline, Venlafaxine.
  • CGRP mAbs: Erenumab, Fremanezumab, Galcanezumab, Eptinezumab (quarterly IV).

Second-line

  • Calcium channel blockers (Verapamil), Lisinopril, Candesartan, Memantine, Cyproheptadine.

Medication Overuse Headache (MOH)

≥15 days/month of acute meds (triptans, ergots, opioids, combination analgesics) or ≥10 days/month (simple analgesics) → worsens headache. Treatment: withdrawal + bridge therapy + preventive initiation.

Consult a Neurologist/Headache Specialist

For refractory, chronic, or atypical headaches; medication selection tailored to comorbidities, pregnancy, preferences.

Headaches - Related Articles