Acute (Abortive) and Preventive Treatment Options
Migraine is a primary headache disorder that involves abnormal pain processing within the trigeminal nerve system. Because of this, the diagnosis and treatment of migraine—including prescribing medication—is within the scope of care of an orofacial pain specialist.
Migraine treatment typically includes:
- Acute (abortive) medications to stop or reduce attacks
- Preventive medications to decrease frequency, severity, and duration
Medication selection is individualized and based on headache pattern, medical history, coexisting conditions, and response to prior therapies.
Acute Migraine Medications (Abortives)
Abortive medications are taken at the onset of a migraine attack to relieve pain and associated symptoms.
Triptans
Examples: sumatriptan, rizatriptan, zolmitriptan, eletriptan, naratriptan, frovatriptan
What they do:
Triptans act on serotonin receptors involved in migraine pathways and are designed specifically to stop migraine attacks.
Key points:
- Most effective when taken early in the attack
- Available in oral, nasal, and injectable forms
- Not appropriate for all patients, depending on cardiovascular history
CGRP Receptor Antagonists (“Gepants”)
Examples: ubrogepant (Ubrelvy), rimegepant (Nurtec ODT), zavegepant (Zavzpret)
What they do:
These medications block calcitonin gene-related peptide (CGRP), a key molecule involved in migraine pain signaling.
Key points:
- Useful for patients who cannot tolerate or do not respond to triptans
- Some gepants are used for both acute and preventive treatment
- Do not cause vasoconstriction
- Less side effects than triptans
Ditans
Example: lasmiditan (Reyvow)
What they do:
Migraine-specific medication that affects serotonin pathways without the vasoconstrictive effects seen with triptans.
Key point:
May cause significant sedation; driving restrictions apply after use.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs) and Analgesics
Examples: ibuprofen, naproxen, acetaminophen, combination analgesics
What they do:
Reduce inflammation and pain during mild to moderate attacks or as part of a stepped treatment plan.
Important consideration:
Frequent use can contribute to medication-overuse headache.
Antiemetics
Examples: metoclopramide, prochlorperazine, ondansetron
Used to treat migraine-associated nausea and vomiting and may improve absorption of other medications.
Preventive Migraine Medications
Preventive therapy is considered when migraines are frequent, disabling, prolonged, or when acute medications are required too often.
The goal of prevention is to reduce attack frequency, intensity, and duration.
CGRP Monoclonal Antibodies (Preventive Injections)
Examples:
- Aimovig (erenumab)
- Emgality (galcanezumab)
- Ajovy (fremanezumab)
What they do:
These medications reduce migraine activity by targeting CGRP signaling over time.
Key points:
- Administered monthly or quarterly
- Response is typically assessed over several weeks to months
Tricyclic Antidepressants
Examples: amitriptyline, nortriptyline
Why they’re used:
Help modulate pain pathways and may improve sleep and muscle-related pain.
Key point:
Often taken at night due to sedating effects.
Antiseizure Medications
Examples: topiramate, valproate/divalproex
Why they’re used:
Stabilize nerve excitability and reduce migraine susceptibility.
Beta-Blockers
Examples: propranolol, metoprolol, timolol
Why they’re used:
Effective for migraine prevention in many patients, particularly when hypertension or tremor is also present.
Calcium Channel Blockers
Example: verapamil
Used selectively in migraine prevention based on individual clinical profile and headache pattern.
OnabotulinumtoxinA (Botox®) for Chronic Migraine
For patients with chronic migraine (≥15 headache days per month with migraine features on ≥8 days), Botox injections may be used as a preventive treatment.
Medication Overuse Headache
Using acute migraine medications too frequently can lead to medication-overuse headache, where headaches become more frequent and harder to treat.
A balanced treatment plan typically includes:
- Appropriate limits on acute medication use
- Preventive therapy when indicated
- Addressing contributing factors such as sleep, stress, jaw clenching, and muscle overuse
How Migraine Medications Fit Into Orofacial Pain Care
Migraine commonly overlaps with:
- Facial pain
- Jaw and TMJ-region pain
- Tooth pain without dental disease
- Neck and shoulder muscle pain
These symptoms share trigeminal nerve pathways. As an orofacial pain specialist, care includes:
- Diagnosing primary headache disorders
- Prescribing and managing migraine medications
- Monitoring response and side effects
- Identifying jaw, muscle, sleep, and behavioral contributors
- Integrating medication therapy with conservative, reversible treatment approaches
The goal is comprehensive migraine care—not medication alone.
Frequently Asked Questions
What is the difference between abortive and preventive migraine medications?
Abortive medications are taken during a migraine attack to stop or reduce symptoms. Preventive medications are taken regularly to reduce how often migraines occur and how severe they are.
What are triptans used for?
Triptans are migraine-specific abortive medications used at the onset of an attack. They are most effective when taken early.
What are CGRP medications?
CGRP medications target a key pathway involved in migraine. Gepants are oral CGRP receptor antagonists used acutely (and sometimes preventively), while CGRP monoclonal antibodies are preventive injections.
When should preventive treatment be considered?
Preventive treatment is considered when migraines are frequent, disabling, prolonged, or when acute medications are used too often.
Can migraine medications cause more headaches?
Yes. Overuse of acute medications can lead to medication-overuse headache, which increases headache frequency.
Can migraine present as jaw, tooth, or sinus pain?
Yes. Migraine can cause facial pain, tooth pain, sinus-like pressure, and jaw or neck pain due to trigeminal nerve involvement.