Migraine medications to the rescue

So in the previous few posts I talked about the lifestyle factors important for migraine and headache patients.  But even someone with excellent self-care, can still suffer from a migraine attack. After all, we have no control over weather changes, fire alarms, Aunt Betty’s strong perfume and other common triggers.  So let’s talk about medications and strategies for rescue.  Developing an individualized rescue plan is the key to living with migraine, rather than suffering from migraine.

There are 3 different types of medications that are important in migraine rescue therapy: migraine abortive, analgesia, and adjuncts.  Migraine abortive medications are those medications specifically designed to stop the migraine attack. Analgesia reduces the pain, and adjuncts enhance the effects of the analgesia and treat the other symptoms.

Migraine abortive medications specifically target migraine. These are migraine medications that stop the migraine in its tracks. They need to be taken early in the attack during the aura phase or before pain becomes severe to be effective.  When time has gone by and pain scores are high, taking an abortive medication is a waste of an expensive pill.

The original migraine abortives are ergotamine and dihydroergotamine (DHE).  Ergotamine was modestly effective, but is not really used anymore due to significant side effects of the cardiovascular and gastrointestinal systems.  It is not well tolerated and there are many more effective choices.

Dihydroergotamine (DHE) has also been around for years and is fairly effective.  The side effects are similar to ergotamine but less extreme. It is available in a number of formulations (IV, SQ, IM) but most commonly used nasally (called Migranal) as an outpatient. The most common side effects are nausea, abdominal pain, muscle aches and stiffness, and paresthesia. Sometimes patients who are having prolonged intractable migraine are admitted to the hospital for several days for IV DHE. The patients are preemptively treated with a variety of antiemetics, such as metoclopramide (Reglan) with Benadryl, ondansetron (Zofran), prochlorperazine (Compazine) or even lorazepam (Ativan for the anxious), and lots of IV fluids. This can be quite effective in reducing a difficult course of migraine, but so unpleasant that we use it sparingly.  This is done inpatient so the kids can be appropriately monitored.  So IV DHE is not our first course of treatment but sometimes you need it, and it can work.

The triptans are the next generation of migraine abortive medications, technically selective 5-hydroxytryptamine receptor 1B/1D agonists. Triptans are effective and safe to treat acute migraine episodes, if you avoid contraindications. For our population, the most common contraindication is basilar migraine, uncontrolled hypertension or allergy; not many teens have angina or ischemic heart disease.  Caution also has to be used with other medications, such as SSRIs and TCAs, due to the risk of serotonin syndrome. As-needed use of a triptan is not contraindicated for someone who is on a daily medication, such as Prozac or amitriptyline- it’s a matter of frequency and dose.

The first triptan to be developed was sumatriptan (Imitrex), and it is available in a number of formulations (SC, PO, nasal).  There is also zolmitriptan (Zomig), naratriptan (Amerge), rizatriptan (Maxalt), almotriptan (Axert), eletriptan (Relpax), and frovatriptan (Frova).  I prefer to use the generic name to avoid my own personal confusion.

For our kids and teens, there are several approved by the FDA for safety. Rizatriptan is approved from age 6, zolmitriptan and almotriptan from age 12, sumatriptan from age 18 but has been trialled in younger teens. Naratriptan, eletriptan, and frovatriptan (good for menstrual migraine) are not approved under age 18 years.  Several of these triptans come formulated as a nasal spray or dissolvable tablet (ODT), which can be helpful for kids with nausea especially.  Any of these triptans can be effective in aborting a migraine if taken as early as possible (during aura or at the very start of migraine), and there’s no real predicting which one will work best. Side effects include a feeling of pressure in the chest, tingling/paresthesias, muscle tightening, dizziness, hot flashes, neck pain, and nausea.  Frequently these medications can cause drowsiness, which can be a good thing.  I encourage kids to take their triptan and then rest/nap for an hour to allow the medication to work.  All medications for migraine work best if there is restorative rest with it- not sleeping all day, but a nap will do.

A few other tips:

Because they have ‘weird’ or unexpected side effects, I always advise taking it for the first few times at home with a calm reassuring parent. And don’t bring it to school for the nurse to give, until you know how it affects your child.

Triptans can be taken with other medications, such as an NSAID and/or antiemetic.  If the effect of the triptan is unpredictable, this is a good way to treat the migraine episode.  Taking the medications all together can better ensure effective treatment. Hit the migraine fast and hard.

Triptans vary widely in price, usually determined by the patient’s health insurance coverage. Sometimes in our EMR, we can tell which ones are going to be cheaper for the patient, but not always.  The local pharmacy can be very helpful in identifying which triptans are covered and are the least expensive.   I will choose an age-appropriate drug and dose, and then ask the family to check at the pharmacy when they go to pick it up, if the chosen drug is the best value.  If it’s not, and another medication is appropriate, the pharmacy can reach out to me with that information, so I can make a more cost-effective choice.  The difference in price can be shocking- $20 for one drug and $150 for another comparable drug.  Apart from providing good clinical care, I feel that making economical choices is important as well.

It is not uncommon to have to try several triptans to find the one that works best. I stick to the appropriate and approved medication to start, and go from there.  Keeping good medical records about what has been tried and worked (or did not) is very helpful, especially when you have to get the Prior Authorization (PA), which is frequently required.

Good data collection by the families is also important.  My patients know I want to know how often they tried the medication, when they took it (during aura, at onset of pain or an hour after the migraine starts), how well it worked, if they took it with something else (NSAID, anti-emetic).  I love good data.

Keeping a diary or even just putting data on your Google calendar is helpful in making good decisions.  The Migraine Buddy app is really helpful in tracking migraines, medicatons, etc.  You can easily personalize the information collected and the medications used.   Again, it’s all about collecting good data.

To keep this blog in tasty but bite-sized pieces, I will stop here.  In the next post, I will cover analgesia and adjuncts.   Please feel free to contact me with any questions or topic suggestions.

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