My last posts have focused on migraine abortives and analgesia for kids with migraine. Here I will continue to review medications and strategies for rescue, focusing on adjuvants and combination medications. These medications are the 3rd leg of the plan which are used to treat migraine. .
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 adjuvants 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.
Adjuvant medications are those that are given with analgesia and/or abortives 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. I will often encourage taking an adjuvant with analgesia at the same time, and if appropriate, with their abortives (triptan or gepant).
The most common adjuvants are anti-emetics, 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 (tab or dissolve tab/ODT) is also useful for nausea, generally does not cause drowsiness. Prochlorperazine (Compazine) and metoclopramide (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. Some of these medications are much better tolerated orally than intravenous (IV), like compazine, benadryl and reglan.
Other options used IV in the ED are steroids, such as dexamethasone; anticonvulsants, such as depakote; or magnesium, If a patient has had any of these in the ED, they could be used orally as an outpatient rescue as well.
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 anti-emetic, 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 anti-emetic is a good combination. With the newer medications (gepants), I advise taking with an anti-emetic since they often trigger nausea.
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 in a current labelled bottle with the school nurse as well, as well as a note from a provider with instructions. 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, so 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 high 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 topically, gently massaged on the temples or behind the ears, some are available in roll on form.
- Ice/cold (or heat) applied to the forehead or the neck
- Gentle massage to the neck and occiput or frontal/temples
- Using an acupuncture pressure point to relieve pain
- Anything that activates the relaxation response, such as a CBT or biofeedback exercise, breathing technique, using a relaxation/meditation app, soothing music. My favorite phone app for relaxation is the Insight Timer app, and to learn pain management specific CBT techniques is WebMap Mobile.
- Hydration using an electrolyte-rich drink to compliment their daily hydration requirements
- Restorative nap/sleep after taking rescue medications, can go a long way in resolving a migraine
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. Doing this can also lead to the establishment of a chronic pattern of migraine, which really needs to be avoided.
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.