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Treating Migraine : Prescription Pain Relief & Prescription Abortive Therapy

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Prescription Pain Relief

Q: When is it appropriate to use prescription analgesics for migraine attacks?
A: Analgesics, both simple and combination, must be avoided, unless no other medications are available. During pregnancy and for people who cannot take triptans, ergotamine-related medications, or NSAIDs, the use of prescription analgesics may be the only option. If analgesics are used, they must be limited to no more than twice a month. They should never be the first choice for attacks simply because they are cheap as overuse can lead to medication overuse headaches.

Prescribed analgesics

Medications that are prescribed to combat the pain of migraine may be combination analgesics or an opioid analgesic on its own. The combination analgesics consist of acetaminophen and/or aspirin together with one or more of the following: caffeine, codeine, or sedatives (butalbital, isometheptene, or dichloralaphenazone).

Prescribed analgesics are generally much stronger than their over-the-counter equivalents. They should be taken carefully and never excessively because if they are overused they can cause more headaches and also place you at significant risk of addiction.

Opioids
  • Hydrocodone 5mg

  • Codeine 30–60mg

Combination analgesics
  • Acetaminophen 325mg with caffeine 40mg and codeine 30mg

  • Aspirin 325mg or acetaminophen 325mg with caffeine 40mg plus butalbital 50mg with or without codeine 30mg

  • Acetaminophen 325mg, isometheptene 65mg, and dichloralaphenazone 100mg


Prescription Abortive Therapy

Q: Which prescription medications are used to stop a migraine attack?
A: Prescription medications used to abort migraine attacks include NSAIDs, triptans, ergotamine, and dihydroergotamine. These medications may be used alone, in combination with each other, or with adjunctive therapy, depending upon the attack. The headache and associated symptoms of a migraine attack vary; therefore your abortive therapy regimen also needs to be flexible.
Q: How will I know which medication to use?
A: Several prescription medications can be used for abortive migraine treatment. Your doctor must tailor your abortive therapy to your attacks. This may take time and means trying various medications until you find a medication that completely aborts your attacks in 2 hours or less.
Q: How will I know when to use my abortive therapy?
A: You need to use your abortive medication as soon as a migraine attack starts. During a migraine attack, you develop gastric stasis (delayed emptying of the stomach), which decreases absorption of medications. Abortive medication must be absorbed into the bloodstream quickly for it to stop a migraine attack.
Q: How often can I take medications for a migraine attack?
A: You should not overuse abortive therapy. Ideally, you should not have to use your abortive therapy more than 1 day a week. If you are experiencing more than 1 attack a week then you need preventive medication, or a medication change if you are using preventive therapy.
Q: How can I be more confident about my migraine attack treatment?
A: An effective abortive therapy is the key. It secures you in the knowledge that if and when you have a migraine attack, you can control it, instead of getting stressed and triggering another attack. As time passes, you will become more confident in your abortive therapy.
Q: What are triptans?
A: The triptans are a group of medications that abort the migraine process and stop the headache of a migraine attack. Their effectiveness is time-dependent; if triptans are used too late in an attack they do not work well. The addition of triptans to your abortive treatment can help with the final step in “switching off” the migraine attack.
Q: How do triptans work?
A: The triptans “switch off” a migraine attack. A migraine attack occurs because the “calming” brain chemical serotonin does not function properly, resulting in the overactivity of brain cells and nerves. The triptans work like serotonin, attaching themselves to serotonin receptors and “switching off” the brain cells and nerves that are excited during a migraine attack.
Q: Are there different types of triptan?
A: There are several different triptans: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan. Each can be very effective, although they vary in effectiveness among different people: what works for one person may be less helpful for another. Your doctor will supervise you while you try each one to determine which triptan is best for your migraine attack and has the least side effects.
Q: Can medications combine a triptan and an NSAID together?
A: Yes. There is a new combination pill containing sumatriptan and naproxen that is pending approval from the Food & Drug Administration (FDA). It makes use of technology that allows the different medications to be absorbed in a timely fashion. The triptan is absorbed quickly to allow it to stop the migraine. The NSAID has been changed to be absorbed quickly but stay longer in the blood, allowing the pill to better abort the attack.
Q: What are the potential side effects of triptans?
A: The common side effects caused by the use of triptans are tingling, warmth, dizziness, flushing, chest discomfort, and sensations of pressure. These side effects vary from one person to another. One of the triptans may cause you to experience side effects while another does not. The side effects do not cause harm and usually last only a few minutes. People with medication overuse headache may experience more intense side effects.
Q: What are the safety precautions for the use of triptans?
A: Triptans can cause coronary vasospasm (spasm of arteries in the heart), and therefore should not be given to people with coronary artery disease or who have had a heart attack or to people with symptoms or findings that indicate significant underlying cardiovascular disease. The triptans can raise blood pressure so they should not be given to people with uncontrolled hypertension. Hemiplegic and basilar migraine should not be treated with triptans, and triptans should not be used during pregnancy. You need to avoid using different triptans, or a triptan and an ergotamine-related medication, on the same day.
Q: How are ergotamine and dihydroergotamine used to treat migraine attacks?
A: Medications containing ergotamine are now rarely used because of the development of triptans. However, dihydroergotamine can be especially effective for severe migraine and migraine of long duration, such as menstrual migraine. Dihydroergotamine is available in the form of a nasal spray and an injectable formulation. The dose for the nasal spray is 5mg and the dose for the injectable formulation is 0.5–1mg. Ergotamine causes significant nausea and has more potential for causing artery spasm than does dihydroergotamine.

Prescribed NSAIDs

Most NSAIDs, except aspirin, ibuprofen, and naproxen sodium, require a prescription. If the migraine is not aborted in 2 hours or less with aspirin or other NSAIDs, then these medications need to be combined with another migraine abortive therapy, using either triptans or dihydroergotamine .

Table
NSAIDFormDosage
Tolfenamic acidpill1,000mg
Pirprofenpill200mg
Indometacinsuppository75–100mg
Ketoprofensuppository100mg
Diclofenacsuppository75mg
Ketorolacinjection60mg

Safe use of NSAIDs
  • NSAIDs in pill form should be taken with food and water to avoid gastrointestinal upset.

  • The overuse of NSAIDs can cause stomach problems and should be avoided if you have medical problems associated with gastro-intestinal bleeding or ulcers, and/or are taking medications that interact with NSAIDs.

  • NSAIDs can complicate high blood pressure and heart disease; make sure your doctor knows if you have one of these medical conditions.

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