Migraine medications, compared

Starts in: Tablets ~30-60 min; the injection and nasal spray work faster

The original triptan and the most-used first-line option for moderate-to-severe attacks; it comes as a tablet, nasal spray and self-injection for when nausea or speed matters. Two labeled rules apply to every triptan: do NOT take one within 24 hours of another triptan or of any ergotamine/DHE product, and they are contraindicated with an MAO-A inhibitor now or in the past 2 weeks. Beyond heart disease and stroke, the labels also contraindicate them in hemiplegic or basilar migraine, Prinzmetal's (vasospastic) angina, peripheral vascular disease, ischaemic bowel disease and accessory-pathway arrhythmias such as WPW. Sumatriptan is additionally contraindicated in severe liver impairment. Best taken as early in the attack as possible.

Starts in: ~30 min, among the faster-acting oral triptans

A fast-acting triptan that also comes as an orally-disintegrating tablet (Maxalt-MLT) taken without water — useful mid-attack. The dose is lowered if you take propranolol. Two labeled rules apply to every triptan: do NOT take one within 24 hours of another triptan or of any ergotamine/DHE product, and they are contraindicated with an MAO-A inhibitor now or in the past 2 weeks. Beyond heart disease and stroke, the labels also contraindicate them in hemiplegic or basilar migraine, Prinzmetal's (vasospastic) angina, peripheral vascular disease, ischaemic bowel disease and accessory-pathway arrhythmias such as WPW.

Starts in: ~45 min oral; nasal spray works faster

Another effective triptan, with a nasal spray option that can help when nausea makes swallowing hard or a faster start is needed. Two labeled rules apply to every triptan: do NOT take one within 24 hours of another triptan or of any ergotamine/DHE product, and they are contraindicated with an MAO-A inhibitor now or in the past 2 weeks. Beyond heart disease and stroke, the labels also contraindicate them in hemiplegic or basilar migraine, Prinzmetal's (vasospastic) angina, peripheral vascular disease, ischaemic bowel disease and accessory-pathway arrhythmias such as WPW. Zolmitriptan's dose is capped in moderate-to-severe liver impairment.

Starts in: ~1-2 hours

A newer 'gepant' (CGRP receptor blocker) for acute attacks. Because it does NOT narrow blood vessels, it is an option for people with heart disease or stroke risk who cannot take triptans — but it is not restriction-free. It is CONTRAINDICATED with strong CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin), the dose must be reduced with moderate ones such as verapamil, and it should be avoided in end-stage kidney disease. Note too that the gepant labels warn of new or worsening high blood pressure and of Raynaud's, so blood pressure still needs watching. It is an option for people who cannot take triptans — the key advantage of this class.

Starts in: ~1-2 hours

A gepant that is unusual in doing two jobs: an orally-disintegrating tablet that treats an acute attack, and, taken every other day, also helps PREVENT migraines. Avoid it with strong CYP3A4 inhibitors or inducers, avoid a second dose within 48 hours if you take a moderate CYP3A4 inhibitor or a potent P-gp inhibitor, and avoid it in severe liver impairment (Child-Pugh C). Like other gepants it does not narrow blood vessels.

Starts in: ~1-2 hours

A 'ditan' that relieves attacks without narrowing blood vessels, so it too is an option when triptans are off the table. Do not combine it with alcohol or other sedating drugs, serotonin syndrome has been reported when it is taken with serotonergic antidepressants, and it is not recommended in severe liver impairment. The trade-off: it is sedating and its label warns not to drive or operate machinery for at least 8 hours after a dose, and it is a controlled substance.