Migraine medications to the rescue…..adjunct and combination therapies

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.

Adjuncts

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.

Treatment Combinations

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.

Migraine medications to the rescue

So in the previous few posts I talked about the lifestyle factors important for migraine and headache patients.  But even someone with excellent self-care, can still suffer from a migraine attack. After all, we have no control over weather changes, fire alarms, Aunt Betty’s strong perfume and other common triggers.  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.

Migraine abortive medications specifically target migraine. These are migraine medications that stop the migraine 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 is fairly effective.  The side effects are similar to ergotamine but less extreme. It is available in a number of formulations (IV, SQ, IM) but most commonly used nasally (called Migranal) as an outpatient. The most common side effects are nausea, abdominal pain, muscle aches and stiffness, and paresthesia. Sometimes patients who are having prolonged intractable migraine are admitted to the hospital for several days for IV DHE. The patients are preemptively treated with a variety of antiemetics, such as metoclopramide (Reglan) with Benadryl, ondansetron (Zofran), prochlorperazine (Compazine) or even lorazepam (Ativan for the anxious), and lots of IV fluids. This can be quite effective in reducing a difficult course of migraine, but so unpleasant that we use it sparingly.  This is done inpatient so the kids can be appropriately monitored.  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.  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.

For our 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 has been trialled in younger teens. Naratriptan, eletriptan, and frovatriptan (good for menstrual migraine) are not approved under age 18 years.  Several of these triptans come formulated as a nasal spray or dissolvable tablet (ODT), which can be 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.

A few other tips:

Because they have ‘weird’ or unexpected side effects, I always advise taking it for the first few times at home with a calm reassuring parent. And don’t bring it to school for the nurse to give, until you know how it affects your child.

Triptans can be taken with other medications, such as an NSAID and/or antiemetic.  If the effect of the triptan is unpredictable, this is a good way to treat the migraine episode.  Taking the medications all together can better ensure effective treatment. Hit the migraine fast and hard.

Triptans vary widely in price, usually determined by the patient’s health insurance coverage. Sometimes in our EMR, we can tell which ones are going to be cheaper for the patient, but not always.  The local pharmacy can be very helpful in identifying which triptans are covered and are the least expensive.   I will choose an age-appropriate drug and dose, and then ask the family to check at the pharmacy when they go to pick it up, if the chosen drug is the best value.  If it’s not, and another medication is appropriate, the pharmacy can reach out to me with that information, so I can make a more cost-effective choice.  The difference in price can be shocking- $20 for one drug and $150 for another comparable drug.  Apart from providing good clinical care, I feel that making economical choices is important as well.

It is not uncommon to have to try several triptans to find the one that works best. I stick to the appropriate and approved medication to start, and go from there.  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.  My patients know I want to know how often they tried the medication, when they took it (during aura, at onset of pain or an hour after the migraine starts), how well it worked, if they took it with something else (NSAID, anti-emetic).  I love good data.

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, medicatons, etc.  You can easily personalize the information collected and the medications used.   Again, it’s all about collecting good data.

To keep this blog in tasty but bite-sized pieces, I will stop here.  In the next post, I will cover analgesia and adjuncts.   Please feel free to contact me with any questions or topic suggestions.

All about the Migraine….part 2

So you have identified one of your patients as having migraine. Now decisions have to be made about management. Important points to consider are: frequency of migraine, intensity of pain and/or associated symptoms, triggers, and lifestyle factors.  Unless the patient is presenting with frequent or intractable migraine several times/week, the first things to review with the patient and family are basic headache-healthy lifestyle guidelines.

What are the most important lifestyle factors to consider in migraine (or any headache for that matter)? Hydration, diet, sleep, exercise/activity, and stress management.  Helping families understand what they can do to reduce migraine is empowering and creates a sense of partnership.  Some families may want to go straight to daily preventive medications, but most would rather start with the basics.

Suggested recommendations:

Hydration is probably the most important aspect of preventing migraine in kids and teens.  I usually recommend that patients drink the equivalent of their weight in kilograms (50kg = 50 oz), or half their weight in pounds (100lbs = 50 oz). This works for patients up to 80kg; above that weight, I will recommend 80-100oz/day.  I have found that families need a real number to aim for, rather than just saying to ‘drink more’, which greatly improves compliance.  I strongly encourage bringing a refillable water bottle to school daily, and bringing it home empty. Most bottles are 20-24oz, and kids who drink during school generally meet their hydration requirements.  Appropriate hydration includes water, seltzer, electrolyte-rich fluids, milk, juice, and do not include caffeinated beverages or soda. Neither sugary nor sugar-free sodas are great, because both high sugar and artificial sweeteners are migraine triggers. If the kids balk at water, a little juice added can help. Some schools do not allow water bottles, but a note from a provider will help (or it can be a part of a 504 education support plan).  I encourage using electrolyte-rich fluids around heavy athletic activity or during migraine, but not as a daily beverage- can lead to obesity or dental caries due to sugar.

Diet is important in a variety of ways.  For some migraineurs, there are foods that can trigger migraines and need to be identified and avoided. There are lists of these foods readily available and I will attach a list here (Headache Elimination Diet).  I tell kids that as a person with migraine, they have to be a detective for their triggers, again empowering them to have agency in their own health. In addition, ensuring regular meals- breakfast, lunch and dinner plus snacks- is key in preventing migraine.  Meal skipping can trigger migraine and many patients have learned this the hard way. Also a diet as varied and nutritious as possible is just good for health.  Some children are very selective (‘picky’), and can be lacking in essential nutrients.  Kids who eat a ‘beige’ diet, eating few if any vegetables or fruits, probably would benefit from a multivitamin.  A common migraine supplement is vitamin B2 (riboflavin) and children with limited diets would benefit from a B complex vitamin.

Getting enough sleep is crucial in the prevention of migraine.  Depending on their age, children and teens need between 8-12hours of sleep per night.  In addition to getting to bed on time, using good sleep hygiene, including bedtime routines and managing time on electronics, is key to adequate sleep.  In our busy, over-scheduled lives, prioritizing sleep can be difficult.  Families just need to understand how inadequate sleep can affect the migraineur.  This might mean that the tween avoids sleepovers, as she knows that a migraine is likely the next day. Or that strict limits on electronics- using phone, tablet, video games, etc- are consistent and enforced. There are many barriers to getting enough sleep, including heavy homework loads, multiple sports or other activities, as well as early start times for high school.  Many communities are beginning to address the start time issue, but families are encouraged to be proactive in setting limits on participation in activities. Inadequate or disrupted sleep is a common migraine trigger.

I’ll continue to review lifestyle factors in the next post. Most of the recommendations apply to all headache types for the most part and are worth a discussion with all families.

Welcome to the HeadFirst PNP blog

Hi, my name is Vickie and I am a PNP working in pediatric headache/pain medicine for the past 10+ years.  I’ve been a nurse for 37 years and a PNP for 21 years, so I have plenty of experience under my belt.  I’ve started this blog to share some information and insights I have gained over the years, with other providers and colleagues.

Headaches are one of the most common reasons that patients visit their pediatricians. There is a lot of information out there about headaches, most of it geared to adults.  I looked around the blogosphere and only found blogs about headaches/migraines by people who suffer with headaches, particularly migraineurs.  While many of these blogs are interesting, none really looked at the headache world from a provider’s perspective.  So I decided to create my own information stream, sharing helpful guidelines and strategies, up and coming research initiatives, and personal insights.

Headaches in children and teens are different from those in adults. There are many reasons why, such as genetics, biological, psychological and sociological factors, school and environmental factors.  What I do know is that headaches are a source of frequent school absence, family disruption and unnecessary pain.  By sharing my thoughts and ideas, I hope to improve the lives of both our patients/families and those who so diligently care for them.

Join me for a ride on the headache rollercoaster!