For some people, treatment aimed at eliminating headaches after they have started is better than taking preventative medication each day, and even those who take prophylactic medication may still experience “breakthrough” headaches and need specialized treatment for acute headaches. These are two general rules you should remember:
1. These drugs shouldn’t be taken too often, as side effects may worsen at higher dose. Additionally, overuse of abortive agents can lead to rebound headache or analgesic overuse headache, i.e., headaches caused by drug overdose.
2. Aside from DHE, injectable sumatriptan, opioids and intranasal butorphanol, you should take abortive medications as early as possible, when you start to feel first signs of headache. Do not wait until the headache progresses as you may find it more difficult to treat it effectively.
Your doctors may prescribe these abortive medications:
1. Aspirin: It may seem too obvious, but higher dose of aspirin is often very helpful to lessen acute migraine. Until now, researchers don’t have a complete understanding on aspirin’s mechanism, even so its anti-inflammatory properties are considered to be highly effective in minimizing headache symptoms. It also influences chemicals present in pain nerve pathways throughout our body. Taking too much aspirin may cause stomach upset, and it can be lessened by drinking milk or choosing coated aspirin capsules. Caffeine can enhance its therapeutic effect.
2. Ergotamine tartrate (or cafergot): This drug comes in a few types. The oral preparation is frequently combined with caffeine to improve its absorption in the stomach. Cafergot is a powerful medication which may narrow blood vessels throughout our body, and isn’t recommended on patients with heart disease or hypertension. If taken in higher dose, you may get headaches and decreased blood flow to the extremities, however nausea is the most commonly reported side effects. Ergotamine tartrate is now infrequently prescribed and mostly replaced by triptans.
3. Midrin: It is a combination drug containing isometheptene to constrict dilated cranial arteries, acetaminophen (Tylenol) and a mild sedative. This drug cause less serious nausea when taken in higher dose compared to the ergotamines but unfortunately, it is less potent. It is advised to take one or two capsules immediately after the onset of headache, followed by another every four hours, if necessary. The effectiveness of this medication has not been fully established.
4. Aproxen sodium (Aleve, Anaprox): It is a NSAID and a fast acting agent. Aproxen is usually easy on stomach and can be effective when taken moments after an acute migraine.
5. Indocin (indomethacin): This inexpensive, old-fashioned NSAID is also usually effective when taken minutes after an attack. The likely side effect is “acid reflux” which can be quite problematic on some people.
6. Dihydroergotamine (DHE): A derivative of Ergot and less nauseating than the more common ergotamine tartrate. It is less likely to cause “analgesic overuse headache”. DHE is available in nasal spray and injectable formulations; Migranal is the trade name for DHE nasal spray, it shows better effects when taken a few minutes after headache strikes, before the pain is too intense. Injectable DHE is usually used for severe, acute migraine which is irresponsive to other treatments.
These drugs have revolutionized migraine medication and generally are appropriate to cure common migraines. It is inadvisable to mix triptans with ergots or different brands of triptans in one day. It is allowed to mix different form of the same triptan brand (i.e., sumatriptan tablets and injection). Side effects include neck or chest tightness or tingling on the extremities or face.
1. Sumatriptan (Imitrex): It is an early form of triptans, a family of drugs that resemble serotonin (which is active in migraine), it acts rapidly and are effective for most patients. Common side effects are nausea, neck or chest tightness, and tingling on the extremities or face. Some recurrent headaches may happen after a successful treatment and can be treated by administering a second dose. Just like many headache drugs, treating moments after an attack and with enough dose dramatically minimizes the likelihood of recurrent headaches. Injectable (hypodermic), oral and nasal forms are available. Sumatriptan in oral formulation is a better choice when taken while an acute headache has just begun. Taking a 100 mg tablet tends to be more effective than 50 mg tablet for most patients, if taken early. Latest oral formulations are expected to be more effective than earlier Sumatriptan medications. Injectable Sumatriptan is intended for headaches at moderate to severe intensity, with severe onset or with significant vomiting and nausea.
2. Zolmitriptan (Zomig): The second type of triptans. It is similar in potency and side-effect characteristics compared to oral sumatriptan. Available in melt wafer and tablet forms, in a 5 mg nasal spray and in 2.5 and 5 mg tablets. Wafer form is more convenient, but not more effective or faster than tablets.
3. Rizatriptan (Maxalt): It is an oral triptan, similar to earlier triptans (sumatriptan and zolmitriptan). It is available in melt wafer and tablet formulations. Those who also take propranolol (Inderal) are only allowed to choose the 5 mg dose. Again, the melt wafer is convenient, but less effective than the tablet form.
4. Almotriptan (Axert): It is sold as tablets at 6 mg or 12 mg doses. It has similar characteristics to other oral triptans.
5. Eletriptan (Relpax): It is a recent variant of triptans. It is similar in profile to most “fast-acting” oral triptans.
6. Frovatriptan (Frova) and naratriptan (Amerge): Frovatriptan and naratriptan are different from other oral triptans, as they have longer onset of therapeutic relief, a longer duration of action and less frequent side effects. They are sold as tablets (frovatriptan: 2.5 mg dose; naratriptan: 1 and 2.5 mg doses).
7. Stadol: A nasal triptan that emulates opioid (“narcotic”) drugs. Those who take Stadol may experience nausea, dizziness, or sleepiness.
8. Steroids (decadron, prednisone): They are powerful anti-inflammatory agents that can be used to treat recurrent migraine attack or status migrainosis. Side effects are quite rare in short-term uses, but insomnia, restlessness and upset stomach may occur.
Other Forms of Medications
1. Antiemetics: These are drugs for vomiting and nausea, a common problem for those with acute migraine. Vomiting and nausea can cause more severe headache and sometimes dehydration. Typical agents in this group are prochlorperazine (Compazine) and promethezine (Phenergan). Both are available in suppository and oral forms and act directly to repress headache.
2. A combination of butalbital/acetaminophen/caffeine: It can be effective on those with acute migraine headache, particularly if taken when the discomfort is relatively mild. All individual components have the potential to cause “rebound” headache if taken in large dosage, and the use of these compound drugs should be limited to a maximum of two to three days per week.
3. Oral opioids: These medications may be effective for temporarily “rescuing” someone with acute, debilitating migraine headache. Continuous usages may cause analgesic overuse inducement (rebound) headache, tachyphylaxis (progressive tolerance to the beneficial effects of the opioid), and psychological or physical addiction. Other side-effects often found to this type of drugs include constipation, euphoria, sedation, nausea, and itching (pruritus). Typically, opioid usage should be only for one or two days each week.
4. Caffeine: As previously mentioned, when combined with other oral agents, it may be very effective in treating acute migraine. You should remember, however, that too much caffeine may worsen migraine.