Migraine treatment online: triptans, CGRP, prevention
Migraine treatment has changed more in the past 5 years than the prior 20. Telehealth can prescribe most acute treatments and many preventive medications. CGRP-class drugs (gepants, ditans, monoclonal antibodies) have shifted the standard of care, though insurance approval is the friction.
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Acute treatment
Sumatriptan (oral, nasal, injectable), rizatriptan, eletriptan — triptans, first-line for moderate-severe migraine, ~$10-20/month generic. Avoid if cardiovascular disease history. Ubrelvy (ubrogepant) and Nurtec (rimegepant) — gepants, no cardiovascular contraindication, expensive (~$900/month list price, often covered).
Preventive medications
Daily prevention is worth it if migraines occur >4 days/month. First-line: propranolol, topiramate, amitriptyline — old, generic, cheap. Second-line: CGRP monoclonals (Aimovig, Ajovy, Emgality, Vyepti) — monthly or quarterly injections, very effective, expensive without insurance.
What telehealth can handle
Triptan prescribing, gepant prescribing, oral preventive prescribing, headache diary review, lifestyle counseling (sleep, hydration, trigger identification), specialist referral when needed. CGRP injectable prescribing varies by platform — some bundle with infusion-center referrals.
When to see a neurologist
Sudden severe 'thunderclap' headache, new headache after age 50, headache with neurological deficits (weakness, vision loss), refractory cases not responding to two preventive trials. Telehealth handles the routine; neurology handles the red flags.