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Migraine Acute Management

Migraine Abortive Treatment – NSAIDs – Neuroleptics – Anti-emetics – Triptans – Ergots

Abortive, Acute, or Symptomatic Migraine Attack Treatment

Abortive treatment is what most people usually do for migraine attacks. Pain medications are taken on as needed basis. This approach is reasonable for infrequent migraine.

It is OK to take pain medications on as needed basis for infrequent migraine. When it comes to frequent migraines, it is advised to avoid taking pain medications more often than 2 to 3 days per week, on average. More frequent use may lead to rebound headache and medication side effects.

Migraine headache has to be treated early in the attack for two reasons. Since migraine is associated with gastroparesis, nausea, and vomiting, the absorption of medications taken by mouth may be delayed for hours even if the absence of vomiting. Injections and nasal sprays would still work. At the allodynia stage migraine pain becomes much harder to control and most drugs simply won’t work.

Nonsteroidal Antiflammatory Drugs (NSAIDs), Aspirin, and Tylenol

Aspirin, Ibuprofen (Motrin), Naproxen (Aleve), Diclofenac (Voltaren), and Ketorolac (Toradol) offer substantial relief of symptoms in many patients. Combination of any of them with Caffeine provide additional benefits. Frequent use is associated with potential side effects (mostly stomach and kidney).

Acetaminophen (Tylenol) is predictably less effective but It does worth a trial because of better side effect profile.

Multiple OTC drug combinations for migraine are available, which are reasonably effective: usually combinations of Aspirin, Acetaminophen or Ibuprofen with Caffeine. They are OK, as long as they work.

I strongly recommend avoiding prescription drugs containing Butalbital. It is available almost exclusively in the US and is banned in the rest of the world. Butalbital is notorious for causing dependence and rebound headaches, even though it works well for migraine. Brand names containing Butalbital are Fioricet and Fiorinal.

Neuroleptics and Anti-emetics

Neuroleptics are designed to work in certain psychiatric conditions, such as schizophrenia or bipolar disorder. Many of these drugs have a strong antiemetic (anti-nausea) effect. They relieve gastroparesis, which is common during migraine attack. Gastroparesis is a lack of stomach active movements.

These drugs are sometimes responsible for development of tardive dyskinesia, especially if taken for a long time. Tardive dyskinesia is a type of movement disorder with involuntary facial movements. Having said all that, this group is very helpful in acute management of migraine. They are frequently administered in ER setting.

Prochlorperazine (Compazine) is available in tablets and suppositories. It relieves nausea, gastroparesis and migraine headache.

Metoclopramide (Reglan) improves nausea and gastric emptying and may be effective for headache.

Chlorpromazine (Thorazine) has similar to Reglan treatment results but it has more side effects and is tolerated worse.

Promethazine (Phenergan) is an antihistamine drug. In migraine it is good for nausea relief only. No effect on pain.

Ondansetron (Zofran) is commonly used for chemotherapy related nausea. Pure anti-nausea effect. No effect on stomach emptying. No effect on headache. It is not associated with tardive dyskinesia. Zofran does not improve absorption of other drugs.

Triptans - Designer Drugs for Migraine

All triptans are designer drugs structurally and functionally imitating serotonin. Serotonin is a biologically active chemical involved in many processes in the brain, from pain processing to sleep regulation. Triptans are believed to be working by multiple mechanisms from constriction of blood vessels to suppression of pain processing. They are currently the first line medications for migraine. Triptans have a decent side effect profile and are usually well tolerated.

All triptans have pretty much the same efficacy. The choice is largely determined by the insurance plan coverage. This group of medications is effective only in early stages of migraine headache (before allodynia). They are expensive.

Triptans taken by mouth are divided in two groups:
Group I Triptans have fast onset, high headache response within 2 hours: Sumatriptan (Imitrex), Zolmitriptan (Zomig), Rizatriptan (Maxalt), Almotriptan (Axert), Eletriptan (Relpax).
Group II triptans efficacy is similar to group I in 4 hours but they act longer: Naratriptan (Amerge), Frovatriptan (Frova).
All triptans are available in pills. Imitrex has an injectable form. Imitrex and Zomig are also produced as a nasal spray.

The sooner the drug are administered, the more likely they will work, the lower chance of headache recurrence. Imitrex injection works within 15 minutes, Nasal sprays within about 30 min and pills within 2 hours. Nasal spray works well. Many of my patients do not like it due to unpleasant sensation in the nose. Even less patients are willing to inject themselves.

Triptans did not make a revolution in migraine management, since they work only at the initial stage of the attack but they do work in some people in whom NSAIDs and other drugs have no effect on migraine headache.

Ergots - Well-forgotten but Effective

Once very popular, it’s a pretty much forgotten group of medications for migraine. Dihydroergotamine (DHE) is the only currently available drug from the group. It is reserved for treatment of severe migraine as an intravenous medication in ER or hospital setting.  DHE is available as a nasal spray as well but it is usually not filled in pharmacies.  It is well tolerated by otherwise healthy people and is not recommended for patients with cardiovascular disorders. DHI might work even if migraine progressed to allodynia stage.

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