My last post focused on the migraine abortive medications for kids with migraine. Here I will continue to review medications and strategies for rescue, focusing on analgesia. There are 3 different types of medications that are important in migraine rescue therapy: migraine abortive, analgesia, and adjuncts. Analgesic medications are those used to reduce or eliminate pain. a reduces the pain, and adjuncts enhance the effects of the analgesia and treat the other symptoms. Developing an individualized rescue plan is the key to living with migraine, rather than suffering from migraine.
For migraine treatment, patients often need several medications for rescue. To avoid medication overuse, any analgesia should be used no more than 3 days/week (alone or in combination).
Non-steroidal anti-inflammatory drugs (NSAIDS) are the mainstay of migraine and headache 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 and other headaches, 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. In general a higher dose of ibuprofen is more effective for migraine. Teens can take a dose of 600mg for migraine rescue with better effect. Higher dosing can be used, 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/cap. 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). There is a suspension, 125mg/5ml, bad tasting and I recently found it is no longer available. Using a regular tab, crushing it in grape jelly, maple syrup or chocolate syrup,would be a good alternative to liquid naproxen. I suppose it could be compounded but compounded meds are not usually covered by insurance and can be expensive.
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 and meloxicam.
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/urgent care for severe or prolonged migraine or headache unresponsive to their usual rescue plan, most likely they will receive ketorolac (toradol) IV or IM, as a part of the treatment cocktail. Unfortunately, oral ketorolac is not particularly effective. Patients and families can be taught to use IM toradol at home for acute migraine treatment. For patients over 50kg, the IM dose is 30-60mg, every 6 hours. This might seem like a daunting suggestion but I have many patients doing IM dosing once, mainly because it works best for them.
Nasal ketorolac or Sprix is also available, through mail-order pharmacy only. It does need to be refrigerated, so another NSAID option should be available, if needed. The nasal administration is a little tricky, and not the same as when using a regular nose spray. You squirt the medication into the nostril, 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. Then repeat in the other nostril. It will burn significantly if sniffed up into the nose and sinuses. The company will send a brochure with instructions. I use ‘hold your nose and pant like a dog’ to describe how to do it, which they are unlikely to forget.
Other options: For patients who cannot take NSAIDS:
Acetaminophen (regular or extra strength) can be used, and 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. Care needs to be taken if any viral illness is suspected. They could use Excedrin tension (or generic) instead, which does not contain aspirin, just acetaminophen and caffeine. I would not use either 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. I rarely prescribe it and reserve using it for patients with GI disorders (ex: Crohn’s, IBS) or NSAIDS allergy. Some patients may receive an opioid such as dilaudid in the ED, but I never use this level of opioid; they are not effective, and quite addictive and risky. This is done much more frequently in the adult population.
Another old-school medication often given in the ED or in the community is Fioricet, which is a combination of acetaminophen, aspirin and butalbitol (a barbiturate). It is ineffective, sedating and addictive and not recommended for kids and teens.
Other analgesia strategies: There are several devices used for analgesia during a migraine episode, can be used for teenagers. There is limited insurance coverage and these devices are expensive. But worth a look anyway.
Cefaly is a transcutaneous electrical nerve stimulation (TENS) device that is attached to an adhesive electrode positioned on the forehead. It provides repetitive stimulation of the trigeminal nerve to moderate or suppress pain signals and promote the release of natural endorphins by the brain. It can be used daily for prevention or as needed during acute migraine episodes. The sensation has been described by users as tingling and vibrating, and then pressure. The sensation can intensify and may be particularly bothersome for patients with skin sensitivity (allodynia or central sensitization). It can be safely used by teens and children. The unit is battery operated and uses replaceable pads. It is generally not covered by insurance. You buy the unit outright, and need to purchase replacement pads as needed. There may be financial support options, trial offers or special discounts through the company at www.cefaly.us.
Nerivio is a device that uses smartphone-controlled electronic pulses to create a Conditioned Pain Modulation (CPM) response via remote electrical neuromodulation (REN) for the acute treatment of migraine for episodic migraine. The wearable device is placed on the upper arm, and self-administered at the onset of migraine headache or aura. The phone application controls the treatment, which should be started as early as possible and always within 60 minutes of migraine. A treatment can be repeated if the headache is not relieved or if it recurs. The company has some discounts to encourage trying it out for a reasonable price. Nerivio requires a prescription, probably not covered by insurance. For more information, check out nerivio.com. A completely non-scientific survey of my patients has shown about 50% get some benefit from the device, reducing pain during migraine. I like the low-cost trial option.
Gamma Core is a non-invasive vagus nerve stimulator, promoted for the preventive and acute treatment of episodic cluster headache and migraine headache in adult patients. As soon as migraine starts, patient applies conductive gel to the side of their neck, and then uses the device for a 2-minute gammaCore (nVNS) stimulation treatment. If pain persists, the treatment can be repeated. This is a rental device, not covered by insurance and expensive for most families. Contact www.gammacore.com/.