There are 3 groups of medications that are used to treat a migraine attack: migraine abortives, analgesia, and adjuncts. . We covered the migraine abortives (those medications specifically designed to stop the migraine attack) in the last post. So let’s talk about analgesia now. Analgesics are medications that are used to reduce the pain. Again, developing an individualized rescue plan is the key to living with migraine, rather than suffering from migraine. Patients often need several medications for rescue.
Non-steroidal anti-inflammatory drugs (NSAIDS) are the mainstay of migraine analgesia. These include ibuprofen, naproxen, ketorolac, diclofenac, and others. The side effects are GI, such as gastric distress, nausea, ulcer, hematologic, such as bleeding disorder or platelet dysfunction, or related to allergic reaction. Any of the NSAIDS can be effective in treating a migraine, as long as it is taken early in the episode. Treating as soon as possible is the key to success.
Most people will start out with ibuprofen, which can be very effective. Dosing should be based on weight and age; under age 12 years and 40kg = 10mg/kg, to a max of 40mg/kg/day, and from 12-17 years and over 40kg = 400mg q6h, to a max of 1200mg/day. Higher dosing can be used in older teens but not more than 2400mg/day, not around the clock and/or daily. Interestingly, there is a product called Motrin migraine or Advil migraine which contains solubilized ibuprofen 200mg. It is touted as having a quicker release of medication. I would think that ibuprofen suspension or chewable tabs would work just as well, and in generic form would be cheaper.
Naproxen is used very often and is effective. It does come in a variety of forms, both prescription and over the counter (OTC), all doses q12h. OTC is Aleve, which is 220mg/tab and is a useful formulation for those under 50kg. Over 50kg we usually use prescription strength naproxen 500mg, regular tabs. It also comes in extended release or enteric coated, but for quick action, the regular tabs work best. Naproxen also comes in smaller dosing (250mg, 375mg), and also as a suspension, 125mg/5ml, which is quite bad tasting. Using a regular tab, crushing it in grape jelly, maple syrup or chocolate syrup, would be preferable to liquid naproxen.
There are several other prescription NSAIDS, such as Diclofenac and Sulindac, which can be tried also, if these others are ineffective. There are a number of other NSAIDS, but they are not used for rapid action or migraine rescue, such as celecoxib.
Ketorolac is the strongest of the NSAIDS, and comparable to morphine, without the risks of using an opioid. Caution should be used for patients with impaired renal function. Dosing is weight based. If your patient goes to the ED, most likely they will receive ketorolac (toradol) IV or IM, as a part of the treatment cocktail. Unfortunately, oral ketorolac is not particularly effective. We have had patients use IM toradol at home for acute migraine treatment, which does involve teaching and comfort using a syringe and giving the injection. We have families who will do it but not often. We also will give an IM injection in the office if needed.
But there is good news in the world of ketorolac! Nasal ketorolac or Sprix is available now. You used to be able to get it through retail pharmacies. It then went off the market for a while and now it’s back. It is only available through Cardinal health, a mail order pharmacy. While it is a bit of a process to prescribe and administer, I have patients who just love it. It can be a game changer, keeping kids out of the ED. To ePrescribe, you have to choose Cardinal health mail order (distributed by Egalet inc), make sure you document the patient’s weight, best phone number, and that it’s OK for patients under 18 years (they will call you if you don’t). They will reach out to families for insurance information. Delivery by mail is quick. It does need to be refrigerated, so another NSAID option should be available, if needed. The nasal administration is a little tricky; you don’t want to use it like a regular nose spray, inhaling it up into your sinuses- it will burn like crazy. Instead, you squirt it into the nare, squeeze your nose tight, and then breathe through your mouth while the med is absorbed through the mucous membranes in the nose or it runs down the throat. I do a ‘demonstration’, and use the term ‘pant like a dog’ to describe how to do it. The kids are unlikely to forget how to do it, after they watch me pant like a dog. I put more information in Resources.
For patients who cannot take NSAIDS, there is always acetaminophen, dosed weight- appropriately. It can be reasonably effective, especially in combination. Aspirin is included here as well, but should be used in a limited fashion due to the risk of Reye’s syndrome. While most families do not use aspirin as go-to analgesic, they will often use Excedrin migraine (or in generic form), which is a combination of aspirin 250mg, acetaminophen 250mg and caffeine 65mg. This is Ok to use in mid-older teens, but not if any viral illness is suspected. Also not around bedtime, as there is considerable caffeine in this.
For patients who cannot take NSAIDS and for whom acetaminophen is not effective, a weak opioid, such as tramadol, can be used. We rarely prescribe it and reserve using it for patients with GI disorders (ex: Crohn’s) or NSAIDS allergy. Some patients may receive an opioid such as dilaudid in the ED, but we never use this level of opioid- they are not effective, are not necessary and risky.
Another old-school medication often given in the ED or in the community is Fioricet, whch is a combination of acetaminophen, aspirin and butalbitol (a barbiturate). It is ineffective, sedating and addictive and not recommended for kids and teens. I have attached an article here about it. Caruso et al 2015 (Butalbital and pediatric headache- Stay off
So that’s the latest on headache analgesia. In the next post, I will cover adjuncts and combinations of medications that work well to treat a migraine to wrap up rescue options.