Many primary care providers stop at traditional migraine treatments: triptans for acute episodes, and beta blockers, topiramate, or amitriptyline for prevention.^1-3 While these can be effective, they often come with significant side effects—beta blockers can cause fatigue and may worsen asthma, topiramate may cause fatigue, sedation, paresthesias, or cognitive slowing, and amitriptyline can lead to sedation and weight gain.^2-4 Additionally, triptans are contraindicated in patients with certain cardiovascular conditions and can contribute to medication-overuse, or rebound, headaches with overuse.⁵ We offer a range of newer options that may be effective for many patients and, in selected patients, may avoid some of the systemic or vasoconstrictive limitations of traditional therapies.^1,6-8

Nurtec (rimegepant) – An oral CGRP receptor antagonist that can be used both for acute migraine treatment and prevention of episodic migraine.^9,10 Unlike triptans, gepants do not cause direct vasoconstriction, making rimegepant a useful option to consider for patients who cannot take triptans because of cardiovascular contraindications or risk factors.^8-10 For prevention, it is taken every other day and has been shown to reduce monthly migraine days, with tolerability similar to placebo in a randomized trial and without the cognitive or weight-related adverse effects that can limit some traditional preventives.^2,3,10,11 It can be used as needed for acute treatment, within labeled dosing limits.¹⁰

Zavegepant – A nasal spray CGRP antagonist for acute migraine treatment.¹² Offers rapid onset, with pain relief reported as early as 15 minutes in one clinical study, and is particularly useful for patients with nausea who can’t tolerate oral medications or those who need a non-oral acute option.^12-14 Like other gepants, it does not cause direct vasoconstriction, so it avoids a key triptan limitation in patients with cardiovascular risk while still requiring medication-specific screening.^8,12

Injectable CGRP monoclonal antibodies (Aimovig, Ajovy, Emgality) – Monthly or quarterly self-injections for migraine prevention, depending on the product and dosing schedule.^18-20 These specifically target the CGRP pathway and clinical trials show that many patients achieve at least a 50% reduction in monthly migraine days.^21-24 They are generally well tolerated and have minimal blood-brain barrier penetration; injection-site reactions, constipation, and blood pressure effects can occur in some patients.^18-21 Particularly valuable for patients who’ve failed multiple traditional preventives, can’t tolerate their side effects, or are appropriate candidates for CGRP-targeting preventive therapy.^1,6,21

We tailor acute and preventive therapy based on your migraine frequency, associated symptoms, comorbidities, cardiovascular risk, and previous treatment responses—not simply what’s most familiar or easiest to prescribe.^1,6,8

References

1. Ailani J, Burch RC, Robbins MS; Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039. doi:10.1111/head.14153
2. Ha H, Gonzalez A. Migraine headache prophylaxis. Am Fam Physician. 2019;99(1):17-24.
3. Lew C, Punnapuzha S. Migraine Medications. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2026. Updated May 1, 2023. Accessed May 25, 2026.
4. Thour A, Marwaha R. Amitriptyline. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2026. Updated July 18, 2023. Accessed May 25, 2026.
5. National Library of Medicine. Sumatriptan tablet prescribing information. DailyMed. Accessed May 25, 2026.
6. Charles AC, Digre KB, Goadsby PJ, Robbins MS, Hershey A; American Headache Society. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: an American Headache Society position statement update. Headache. 2024;64(4):333-341. doi:10.1111/head.14692
7. Yang CP, Liang CS, Chang CM, Yang CC, Shih PH, Yau YC, et al. Comparison of new pharmacologic agents with triptans for treatment of migraine: a systematic review and meta-analysis. JAMA Netw Open. 2021;4(10):e2128544. doi:10.1001/jamanetworkopen.2021.28544
8. Diener HC. The risks or lack thereof of migraine treatments in vascular disease. Headache. 2020;60(3):649-653. doi:10.1111/head.13749
9. Croop R, Lipton RB, Kudrow D, et al. Oral rimegepant for preventive treatment of migraine: a phase 2/3, randomised, double-blind, placebo-controlled trial. Lancet. 2021;397(10268):51-60. doi:10.1016/S0140-6736(20)32544-7
10. National Library of Medicine. Nurtec ODT (rimegepant) prescribing information. DailyMed. Accessed May 25, 2026.
11. National Library of Medicine. Zavzpret (zavegepant) nasal spray prescribing information. DailyMed. Accessed May 25, 2026.
12. Lipton RB, Croop R, Stock DA, et al. Safety, tolerability, and efficacy of zavegepant 10 mg nasal spray for the acute treatment of migraine in the USA: a phase 3, double-blind, randomised, placebo-controlled multicentre trial. Lancet Neurol. 2023;22(3):209-217. doi:10.1016/S1474-4422(22)00517-8
13. Pfizer Inc. Zavzpret (zavegepant) efficacy and study results. PfizerPro. Accessed May 25, 2026.
14. National Library of Medicine. Aimovig (erenumab-aooe) prescribing information. DailyMed. Accessed May 25, 2026.
15. National Library of Medicine. Ajovy (fremanezumab-vfrm) prescribing information. DailyMed. Accessed May 25, 2026.
16. National Library of Medicine. Emgality (galcanezumab-gnlm) prescribing information. DailyMed. Accessed May 25, 2026.
17. Dodick DW. CGRP ligand and receptor monoclonal antibodies for migraine prevention: evidence review and clinical implications. Cephalalgia. 2019;39(3):445-458. doi:10.1177/0333102418821662
18. Goadsby PJ, Reuter U, Hallström Y, Broessner G, Bonner JH, Zhang F, et al. A controlled trial of erenumab for episodic migraine. N Engl J Med. 2017;377(22):2123-2132. doi:10.1056/NEJMoa1705848
19. Dodick DW, Silberstein SD, Bigal ME, Yeung PP, Goadsby PJ, Blankenbiller T, et al. Effect of fremanezumab compared with placebo for prevention of episodic migraine: a randomized clinical trial. JAMA. 2018;319(19):1999-2008. doi:10.1001/jama.2018.4853
20. Stauffer VL, Dodick DW, Zhang Q, Carter JN, Ailani J, Conley RR, et al. Evaluation of galcanezumab for the prevention of episodic migraine: the EVOLVE-1 randomized clinical trial. JAMA Neurol. 2018;75(9):1080-1088. doi:10.1001/jamaneurol.2018.1212