Since I am revisiting the topic of caring for kids with migraine, I thought I would jump right into medications next, treatment and then preventive. I am a firm believer in headache healthy lifestyle factors and their important for preventing migraines. I have discussed these quite a bit in the blog. 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. This post will be devoted to abortives. There are a few new medications on the market now.
Migraine abortive medications specifically target migraine. These are migraine medications that stop the migraine train 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 can be effective when a patient has a lengthy intractable migraine or a pattern of frequent migraine. The side effects are similar to ergotamine but less extreme. It is available in a number of formulations (IV, SQ, IM). As an outpatient, it is used nasally, called Migranal, (sadly very hard to get insurance approval). The most common side effects are nausea, abdominal pain, muscle aches and stiffness, and paresthesias. These patients are admitted to the hospital for several days (5-6 doses) for IV DHE for appropriate monitoring. The patients are preemptively treated with a variety of antiemetics, such as metoclopramide (Reglan) with Benadryl, ondansetron (Zofran), prochlorperazine (Compazine) and/or lorazepam (Ativan), and lots of IV fluids. This can be quite effective in reducing a difficult course of migraine, but can be unpleasant and disruptive to life and school. There is an initiative within the neurology team in our hospital to have the kids receive it as an outpatient in the infusion unit (2 doses/day usually, coming in daily for 3 days), still in the process of data collection for effectiveness and family satisfaction. In these days of Covid 19 service disruption, this can be useful, to avoid using a valuable hospital bed. But in our clinic, we prefer an inpatient stay, useful to address other issues for our chronic headache patients, including psychological support, partnering with the nursing staff. We are located in a satellite facility, so less of an impact on overall inpatient access. 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, but need to be mindful of any congenital heart defects. 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. Triptans are the gold standard for aborting migraine.
For 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 often used in younger teens. The others are not approved under age 18 years. Several of these triptans come formulated as a nasal spray or dissolvable tablet (ODT), 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.
Gepants and ditans, the new kids on the block: In the past few years, there has been development of a different approach for prevention and now treatment of migraine. There are several oral medications now on the market for migraine treatment, in place of a triptan. None of these medications are approved for those under age 18 but there are ongoing clinical trials to achieve that end.
Calcitonin gene-related peptides (CGRP) are proteins that carry pain signals involved in migraine headache pain. The rescue Gepants, rimegepant (Nurtec) & ubrogepant (Ubrelvy), work to block CGRP from attaching to its receptor and initiating those pain signals. These medications were first approved as rescue medication to be taken at the start of a migraine, to reduce the pain and symptoms with a migraine episode. The main side effect is nausea, which can be mitigated by taking with an antiemetic. They have few other side effects, and don’t cause drowsiness which helps if you have to functional day. These medications are also being explored as preventive medications, taken every 2-3 days.
The Ditan medication, lasmiditan (Reyvow) is an antagonist at the 5-HT 1F serotonin receptor. It does not constrict the coronary or cerebral vessels and is an alternative for those who cannot take the triptans. It can be sedating so less attractive for functioning, with dizziness as a prominent side effect. There is high abuse potential as well.
The gepants are heavily advertised in the media (with Serena Williams, one of the Kardashians, Whoopi Goldberg), so the families are aware of them. Unfortunately it is going to a while before they are readily available and approved by the FDA. And the insurance companies will do their best to put up road blocks as well, The companies do offer copay plans to help defer the cost.
A few other tips:
Triptans vary widely in price, usually determined by the patient’s health insurance coverage. Choose an appropriate for age triptan and modify the choice based on availability for insurance approval and cost.
It is not uncommon to have to try several triptans to find the one that works best. 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. 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, medications, and triggers.
You will always get questions about the ‘new medications’, so it’s good to know a bit about them. I have found it helpful to know what other options are available to gain access to them. There are clinical trials going on, and if you know what is happening in you area, you can always refer them to the trial. We have an adult pain group nearby which is doing trials on the preventive and rescue anti-CGRP medications for ages 12-18 years. The patient participates in the appropriate trial, but return to us for basic headache/migraine care.
That’s it for the migraine abortive medications. In the next post, I will cover analgesia and adjuncts.
HeadFirst PNP 