migraine treatment - headache

Current medications used to prevent migraines are separated into a first, second, and third choice, a hierarchy of sorts that provides a flowsheet of what to do when some medications fail. It is not etched in stone, offered as a guideline only. Many physicians and headache specialists will mix or jump classes according to their own preferences or experience.

1. First choice includes

  1. propranolol (beta-blocker), verapamil (Calan—calcium channel blocker),
  2. amitriptyline (Elavil—antidepressant), and
  3. topiramate (Topamax) and valproate (Depakene)—anti-seizure meds.

 

Pregnancy is a contraindication to valproate, which can cause birth defects. The beta-blockers shouldn’t be used in smokers or people over 60, which may raise the risk of stroke.

 

2. Second choice: for those who don’t respond adequately to the first-choice medications, there are

  1. other beta blockers—atenolol (Tenormin), nadolol, metoprolol (Lopresor), timolol;
  2. botulinum toxin A;
  3. neuromodulators—gabapentin (Neurontin), verapamil); and
  4. other antidepressants—other tricyclic ones like nortriptyline (Aventyl) and protriptylne.

 

If these don’t work well either, there are also third choice drugs:

  1. the herb feverfew;
  2. tizanidine (Zanaflex);
  3. memantine (Namenda);
  4. pregabalin (Lyrica);
  5. cyproheptadine; and
  6. zonisamide.

 

Often, once a migraine starts it is difficult to eradicate, a clinical chasing of one’s own tail. For this reason, most migraine sufferers do best with a preventative approach according to the above scheme of first, second, and third line choices. A single agent that works is the best for both compliance and convenience.

Because a tail is difficult to chase, not only prevention, but a strategy for stopping an oncoming migraine is usually adopted by patients, using simpler medications like ibuprofen, aspirin, or acetaminophen. For acute onset, “triptans” such as sumatriptan and Rizatriptan (see below) can work quickly to end a migraine.

 

The exact mechanism is unknown.” How’s that, you say?

Beta-blockers

Beta-blockers block the receptor sites for adrenaline and noradrenaline (epinephrine and norepinephrine, respectively). The beta receptors, when filled, increase the rate and strength of heart contractions and stimulate blood vessels to constrict (raising blood pressure). These are all part of the fight-or-flight response that depends on good blood flow to the muscles (for fighting or for fleeing to fight another day).

Beta-blockers relax and open blood vessels in the brain, but it is unclear how they help with migraines; nevertheless, they do. Since they help, this debunks the theory that migraines are caused by dilated blood vessels. There are another set of beta receptors in the lungs, which help with lung function and ventilation. For this reason, beta-blockers are avoided if a person has lung problems, such as asthma or COPD.

Side effects are hypotension and trouble breathing.

 

Calcium channel blockers

Like the beta-blockers, calcium channel blockers prevent migraines by reducing the constriction of blood vessels. As is famous in most pharmacological explanations, this is another example of “the exact mechanism is unknown,” which you will no doubt read over and over if you page through a copy of the Physician’s Desk Reference (which, by the way, is as interesting as reading a telephone book). Nevertheless, like the beta-blockers, calcium channel blockers are used to treat hypertension and for migraine prevention alike.

Side effects are hypotension and trouble breathing.

 

Antidepressants

The tricyclic antidepressants probably help prevent migraines by altering the serotonin and other neurotransmitters in the brain. (Again, “the exact mechanism is unknown.”)

Side effects include sexual dysfunction, mood changes (hopefully for the better), loss of appetite, and fatigue.

 

Tryptans

These are a newer class of drugs that increases serotonin levels, which reduces inflammation and constricts blood vessels.

 

Anticonvulsants

Although with anti-seizure medications, again, “The exact mechanism is unknown,” it makes sense that anything which dampens the propagation of spontaneous, runaway nerve conduction will help, as in epilepsy, with migraines, too.

Side effects include mood changes, (for the better with Valproate), fatigue, gastrointestinal mayhem (nausea, constipation, diarrhea). Contraindicated in pregnancy, suspected pregnancy, or in sexually active women of childbearing age using unreliable contraception.

 

What about “pain” medicines? Narcotics?

Because of the migraine syndrome resulting in an overstimulation of Cranial Nerve 5—the trigeminal nerve, narcotics inhibit the release of Substance P (as might be guessed, this is a pain-producing substance). However, since migraines are common and recurring, treating them with narcotics is ill-advised, especially in today’s opioid overdose crisis, due to the problems of addiction, dependence, and tolerance. Treating chronic migraines with narcotics has to use chronic narcotics. Interestingly, many physicians feel that certain narcotics can make migraines worse.

Additionally, since migraine sufferers are often on beta-blockers, which have the risk of respiratory compromise, adding a narcotic—a known respiratory depressant—can be the proverbial double whammy.

 

What about over-the-counter (OTC) medications?

Ibuprofen (Advil, Motrin) often helps with migraine pain in up to half of migraine patients. Whether it is enough or not is a quantitative consideration (“Did it help enough?”). Side effects are gastritis or bleeding.

Aspirin, an anti-inflammatory like ibuprofen, is similar in efficacy and side effects.

Another anti-inflammatory is naproxen.

Acetaminophen (Tylenol), especially combined with coffee, is another strategy patients use as a migraine “aborter.” What the hell? Caffeine? Caffeine is a vasoconstrictor, the opposite of what beta-blockers do. Nevertheless, many swear by acetaminophen + coffee, which are the ingredients in commercial “migraine” medicines like “Tylenol Migraine.”

Mixed preparations. An example is Excedrin Migraine, which mixes both acetaminophen and aspirin, with a splash of caffeine.

 

Every human being is different, and every migraine is different. For this reason, aborting migraines at the outset as well as a maintenance strategy to prevent them is standard operating procedure for those who suffer the debilitating effects of these very costly (employment, relationships, quality of life, healthcare cost) headaches.

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Resources:

  1. http://www.medscape.com/viewarticle/464040_4.
  2. http://www.mdedge.com/jfponline/article/65212/what-are-best-prophylactic-drugs-migraine.
  3. https://www.uptodate.com/contents/preventive-treatment-of-migraine-in-adults?source=search_result&search=migraine%20beta-blockers&selectedTitle=1~150#H5
  4. http://blog.themigrainereliefcenter.com/best-over-the-counter-migraine-medications
  5. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000; 55:754.
  6. Loder E, Biondi D. General principles of migraine management: the changing role of prevention. Headache 2005; 45 Suppl 1:S33.
  7. FDA Drug Safety Communication: Valproate anti-seizure products contraindicated for migraine prevention in pregnant women due to decreased IQ scores in exposed children. www.fda.gov/Drugs/DrugSafety/ucm350684.htm (Accessed on May 15, 2013).


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