There are 3 groups of medications that are used to treat a migraine attack: migraine abortives, analgesia, and adjuncts. We have covered the migraine abortives (those medications specifically designed to stop the migraine attack) and analgesia (used to reduce pain) in the past 2 posts. There are several medications that are used either in combination with others to treat the migraine or to treat other symptoms that happen with migraine. These medications are referred to as adjuncts in migraine therapy, and are often used in combination. Again, developing an individualized rescue plan is the key to living with migraine, rather than suffering from migraine. Patients often need several medications for an effective rescue plan.
Adjunct medications are those that are given with analgesia to complement and enhance the effect and treat other symptoms, such as nausea, dizziness or insomnia. A classic combination is an NSAID with ondansetron (Zofran), or metoclopramide (Reglan) =/- benadryl, or prochlorperazine (Compazine). I will often encourage taking an adjunct with analgesia at the same time, and if appropriate, with their triptan.
The most common adjuncts are antiemetics, those medications which treat nausea associated with migraine. Antihistamines, such as diphenhydramine (Benadryl), meclizine, and/or hydroxyzine (Atarax) are useful in combination with NSAIDs. There is the added benefit of drowsiness, to help facilitate restorative sleep. Ondansetron is also useful for nausea, generally does not cause drowsiness. Compazine and Reglan are seen as primary agents for treating migraine as well as treating nausea. The side effects associated with these 2 medications can be avoided by using them with Benadryl. Dosing is based on weight and age appropriate.
Another option often used in the ED is steroids, such as dexamethasone. If a patient has had this in the ED, they could use this as an outpatient rescue as well. Oral magnesium is sometimes used as a rescue medication too.
Many patients develop a migraine rescue strategy, over time and with experience, that involves a combination of medications. It is always a very individual plan and usually discovered by trial and error. They might have reasonably good results with a triptan plus antiemetic, or triptan plus analgesia. They may have the best results with an ‘attack pack’ of 3 medications taken together, such as sumatriptan, naproxen and Benadryl. In cases when a triptan is not effective, NSAID plus antiemetic is a good combination.
The key is to work with the family, figure out what works best, and then BE PREPARED for the migraine to happen. For younger kids, their parents should always travel with a dose of each of their rescue medications. They need to have several doses of each medication with the school nurse as well. Older teens can have a prepacked plastic bag with 1 dose of each medication that they can carry with them outside of school. (Make sure it’s labelled, for obvious reasons). Most high schools do not allow for self-medication. It is well worth it for the family to have a good relationship and understanding with the school nurse; that when the teen comes to the nurse’s office, they can get their medication promptly and have a chance to lie down and nap for up to 30 minutes at least. Having a clear plan communicated to the school nurse is so helpful. The workload of our school nurses is tremendous, and having a collaborative relationship with them will make rescue therapy much easier and effective for the kids.
Complementary rescue remedies
In addition to the medications we have talked about, there are a number of complementary interventions that can really help resolve a migraine.
- Aromatherapy: using an essential oil, such as peppermint, lavender, ginger, or a specially formulated blend (M’Grain from Young Living products) topically, gently massaged on the temples or behind the ears
- Ice/cold (or heat) applied to the forehead or the neck
- Gentle massage to the neck and occiput or frontal/temples
- Anything that activates the relaxation response, such as a CBT or biofeedback exercise, breathing technique, using a relaxation/meditation app, soothing music. My favorite is the Insight Timer app, so many options and free.
Final rescue thoughts
Having migraine is challenging for the whole family. Migraines often occur at the most inconvenient times, often out of the blue. It’s important to remember that stress is a trigger for most patients, and stress is not always negative. Positive stress, such as excitement about an upcoming vacation trip, can also trigger migraine.
I also cannot emphasize enough how important it is to treat the migraine promptly- hit it hard and fast- for best results and resolution. Giving parts of a rescue plan, half-doses spread out over time, usually just prolongs the episode and makes it more difficult to resolve. And there really is no point in prolonging the agony, especially when it is your kid’s pain.
Being prepared, having rescue medications, and extra electrolyte-rich hydration fluids can go a long way in turning a migraine episode from a disaster into a blip on the radar.