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Headaches and Migraines Treatment

There are a number of options available. Most patients i.e. those who have less than 6-8 headache days per month, will only require abortive treatment (treat the headache when it occurs), others require preventative therapy.

The key to abortive treatment is to treat early and appropriately. Studies now show that as the migraine progresses and the pain increases, gastric stasis occurs. This results in a lack of absorption of oral medications which renders them ineffective. Furthermore, some individuals will experience a rapid onset of their headache symptoms and require delivery options that bypass the gut (nasal or injections). Treatment options include over the counter medications, of which there are 5 major players (everything else is the same medication packaged and sold under a different name. They include; Aspirin, Tylenol, Aleve, Ibuprofen and Excedrin.

For those who do not respond to OTC medications, prescription medications are required. There are 3 major classes: Triptans (Imitrex, Treximet, Maxalt, Relpax, Zomig, Amerge, Axert and Frova) which work on specific serotonin receptors resulting in constriction of blood vessels (vasoconstrictors), are highly effective (80%) if taken appropriately. With the exception of the longer acting forms (Amerge and Frova) there is no significant difference in efficacy among the various types. Available preparations include oral, nasal and injectable and side effects can include chest or throat tightness, fatigue, GI side effects and flushing. Dihydroergotamine (DHE-45 inection and Migranal nasal spray) are a class of medications (Ergots) that have been available for over 50 years. They also work on Serotonin as well as Dopamine resulting in constriction of veins (venoconstrictors). Duration of action can be over 24 hours with and common side effects include nausea and flushing. Both triptans and Dihydroergotamine have the potential to constrict coronary and cerebral blood vessels and are contraindicated in patients with coronary artery disease, heart attack, stroke, uncontrolled blood pressure, blood clots or a risk factor of the above. Prescription NSAID’s include medications such as Toradol (Ketorolac) which is available in an oral and injectable prep, and Cambia. These medications are not quite as effective, however have a better safety profile which makes them more appropriate for use in older individuals. They should not be used in patients with a history of severe kidney disease or ulcers. Other medications often prescribed to abort headaches include Butalbital/Aspirin/Acetaminophen/Caffeine containing compounds (Esgic, Fiorinal, Fioricet), Tramadol (Ultram), Stadol, Demerol and narcotic pain medications. These medications have little effect on migraine physiology (see above) and are notorious for causing medication overuse or rebound headache (see below). If your doctor is currently prescribing these medications see a headache specialist for a second opinion.

Those patients who have more then 6-8 headache days per month or who don’t respond well to abortive medications are candidates for preventative therapy. Often times your physician will choose a preventative based on your underlying medical history. For example is you have high blood pressure, use a blood pressure medication or if you have depression, use an anti-depressant, i.e. use one medication to treat two problems or in other words “kill two birds with one stone”. Anti-epileptic medications which appear to work to lower neural hyper-excitability and migraine threshold are first line preventatives. Drugs such as Topamax, Zonegran, Depakote and Neurontin. These medications are usually well tolerated, lower then number of headache days by about 60% and are contraindicated in pregnancy. Common side effects include drowsiness, trouble thinking, weight loss, weight gain and rare cases kidney stones. Antidepressants are often used in patients who have headache, depression and/or trouble sleeping. There are three main classes of medication: Tricyclic Anidepressants; Amitriptyline and Nortriptyline. Common side effects include dry mouth, drowsiness, and constipation. Selective Serotonin Reuptake Inhibitors (SSRI’s), Prozac, Paxil and Zoloft and Selective Serotonin/Norepinepherine Reuptake Inhibitors (SNRI’s) Effexor, Lexapro, Celexa and Cymbalta. The later two classes likely work on the migraine trigger i.e. depression and anxiety with nausea and decreased sex drive being the most common side effects. These medications take approximately one month to get into the patient’s system and are often difficult to come off of. Recent evidence suggests that Effexor may be the most effective. Patients with high blood pressure often do well with cardiac medications, i.e. beta blockers(Inderal), calcium channel blockers (Verapamil) ACE Inhibitors (Lisinopril). These medications tend to be preferred by primary care doctors, mainly due to their familiarity with use. Side effects can include fatigue and constipation. Vitamins and Minerals have been shown in randomized trials to be effective in migraine prevention in some patients ; Feverfew Butterbur(Petasites hybridus), Magnesium, Vitamin B2 (Riboflavin), Coenzyme Q 10 and melatonin are some examples. Nonsteroidal Anti inflammatory Drugs (NSAIDs), often used in acute treatment, also can prevent migraine. Naproxen and Aspirin are two medications that have shown efficacy. Other medications that have been tried as migraine preventatives include Namenda (used on label for dementia), Antihistamines such as Benadryl and Cyproheptadine (a 5-HT2 antagonist with calcium channel blocking properties), the ergot Methergine (normally used for to induce uterine contraction) and Botox@ which has only been shown to be effective (about a 50% reduction in headache) in large well designed clinical trials for Chronic Migraine (it was not effective in episodic migraine).