Patients who have been diagnosed as having migraine headaches should be taking prescribed abortive treatment, which is also referred to as acute, or as-needed treatment.
Abortive treatments come in various forms, including tablet (pill form), oral powders, nasal spray or powder, and self-administered injection or device use. Choosing an appropriate abortive treatment is a critical step in the treatment of migraine patients.
Each class of abortive treatment discussed below, has its own indication and contraindication and prescribing providers should know each patient’s medical history in order to select the most appropriate option. Patients should be certain to advise their treating physician of any and all other medications and supplements taken for other conditions, as some abortive medications can have drug interactions with other medication or supplements taken.
The main classes of migraine abortive treatments include:
A. SIMPLE ANALGESICS (PAIN KILLER)
These drugs contain an acetaminophen component, such as Tylenol, which sometimes can help with headache in migraine patients.
B. ANTI-INFLAMMATORY MEDICATION
Ibuprofen (Advil) and Naproxen (Aleve) are two available over-the-counter medications than can decrease inflammation and help reduce the pain in migraine headaches. However, there are some prescriptions in this group which are superior to over the counter options, prescription formulations tend to be more effective. Prescribed anti-inflammatory medications also have the benefit of physician control over the number of days a patient can take the medication each month in order avoid the occurrence of rebound headache. There are different types of prescription medication in this class, two of which are most commonly used in migraine. These are:
- Diclofenac potassium: which comes in capsule or powder form. The powder form is called CAMBIA and is dissolved in water and then the patient drinks the solution.
- Ketorolac: which comes in tablet form, nasal spray called SPRIX, or in the form of injection, which is called Toradol.
C. OVER-THE-COUNTER CAFFEINATED ANALGESIC
This class of medication is introduced with the brand name of Excedrin. Considering high amount of caffeine and possibility of rebound headache with this class, we do not recommend it to our patients.
D. ERGOT MEDICATION
This class of medication was the first of its kind that was specifically made for migraine over 50 years ago and is still used today. There are four different formulations available, which include:
- Dihydroergotamine mesylate injection (also known as DHE injection), which is mostly used as headache centers as an intravenous (IV) infusion.
- Dihydroergotamine mesylate nasal spray (Migranal®)
- Ergotamine tartrate sublingual tablets (Ergomar®)
- Ergotamine tartrate with Caffeine tablet (CAFERGOT®)
- There are new nasal formulations of ergot with unique delivery method which are currently in development.
This class of migraine medication was introduced in the early 90s and is still the standard abortive treatment which all migraine patients should be given, unless there is contraindication. Currently, seven triptan medications are in the US market, each of which is slightly different, and therefore failure or side effect to one triptan does not necessarily mean that another triptan will be also be ineffective or cause the same side effect. As such, patients may be switched from one triptan to another in order to find an effective treatment.
- Sumariptan (Imitrex) was the first triptan that introduced and is available in tablet (pill) form, nasal form, including generic nasal spray and non-generic spray (TOSYMRA™), nasal powder form (ONZETRA Xsail), and also in the form of self-injection, including pen injector (Zembrace).
- Other triptans include: Rizatriptan (Maxalt), Zolmitriptan (Zomig), Eletriptan (Relpax), Almotriptan (Axert), Naratriptan (Amerge) and Frovatriptan (Frova).
This is a newer class of migraine abortive medication and the only class that is a controlled drug. Currently, only one medication is available in this class, which is called REYVOW, and comes in tablet form.
This class of medication was introduced to the market in 2020. Two drugs are available in this class:
- UBRELVY: which comes in two different tablets, 50 mg and 100 mg
- NURTEC: which is an oral disintegrating tablet available in 75 mg
Currently, there are different types of devices marketed as migraine treatment. However, patients should be careful about the use of some non-approved devices, which may be marketed as suitable for migraine treatment by some companies. There are however, four devices that have been shown to be effective in migraine. These are:
- Cefaly: Supraorbital and supratrochlear nerve simulation
- sTMS: Single-pulse Transcranial Magnetic Stimulation
- GammaCore®: Vagus Nerve stimulator
- Nerivio: Non-invasive remote electrical stimulation
Nerve block(s) can be used as abortive or preventive treatment for migraine headaches. In certain circumstances, such as pregnancy, where most medications cannot be used, this treatment option could be a reasonable alternative. Another in-office procedure for abortive treatment is Sphenopalatine Ganglion Block. This particular in-office procedure can be done using special devices through the nose through which lidocaine is injected into the back of the nose.
WHAT SHOULD A PATIENT DO NEXT? LEARN!
Considering the variety of treatment options, it is critical for patients to have knowledge about all treatment modalities to help select the right treatment option.
Here at the Kaizen Headache Center, we offer all the above discussed treatments in collaboration with expert physicians in each field. We recommend our patients to review the treatment options in detail prior to their scheduled appointment. As patient’s learn about their options, it is important write any and all questions down so they can be discussed during their consultation.