Treatment
Many effective headache remedies are now available for treating a migraine attack. Still, a 2002 study that analyzed over 800,000 migraine cases, reported that most migraines are not treated according to any expert recommendations or accepted evidence. In the study, 30% of patients were treated with potentially addictive opioids--most often Demerol. Furthermore, 70% of these patients were not offered effective and available anti-migraine drugs. And anti-nausea agents that have no effect on headaches were used six times more often than drugs that reduce headaches.
It should be noted that as many as 30% of migraine sufferers also have accompanying headaches resulting from tension, drugs, infections, or other causes. It is important to distinguish between headache types in order to determine appropriate treatment.
General Guidelines. The general goals of treatment are the following:
- On the advice of the physician, choose drugs with as few side effects as possible. Patients should discuss various methods for administering the medication (pills, injections, nasal spray, or rectal suppositories) and begin with one they believe will be the least distressing.
- Treat the attack rapidly, within an hour of symptom onset if possible. Start with low doses first and build up dosage slowly.
- Try to minimize the use of back-up or rescue medications. (A rescue medication is typically an opiate, which the patient uses at home for pain relief when other medications fail.)
- Try to guard against rebound effect. Nearly all drugs used for migraine can cause rebound headache and none of the drugs should be taken for longer than two days per week. (Dihydroergotamine and newer triptans may pose a much lower risk for rebound than others, although evidence for this is not certain.)
- It may take two to four months for an agent to be effective.
Stepped-Up Treatment Approach. Some experts have advocated a stepped-up treatment course for an acute migraine attack. This involves starting with the least potent treatments and taking increasingly more potent drugs until the pain stops. In this approach some patients need up to five different medications to achieve pain relief. A typical stepped approach is the following:
- Patients first try general pain relievers (NSAIDs, Excedrin Migraine) and stress-reduction techniques.
- If these are not effective within two hours, migraine-specific agents should be tried next. Triptans are the first choice, then ergot derivatives (dihydroergotamine [DHE]).
- Injected or rectally administered drugs may be used for patients with migraines associated with severe nausea or vomiting. Nausea itself should be treated with specific anti-nausea drugs, such as metoclopramide (Reglan).
- If migraine medications fail to relieve symptoms within four hours, rescue drugs (opioids, corticosteroids) may be used.
Stratified Approach. Many physicians and patients now prefer the stratified approach. The doctor first estimates the severity of the patient's condition based on his or her history. Then, based on the severity of a typical attack, the physician decides whether the patient should start with more or less potent agents at the first signs of the migraine:
- Patients with less disabling migraines start with general pain relievers.
- Patients with a history of moderate to severe migraines start with migraine-specific prescription medicine, such as a triptan, at the onset of mild pain.
Some studies report dramatic relief with the stratified approach. In one 2002 study, zolmitriptan, a newer triptan, reduced the intensity of headaches within two hours in 70% of patients with moderate pain but in only 44% of those with severe headaches.
Side effects can be severe with many migraine agents, although newer agents, such as the recent generation triptans, may provide effective early relief without significant adverse effects.
Guidelines for Migraines in Children
Some studies estimate that between 5% and 10% of children may experience migraines but that the disorder is underdiagnosed in children. An interesting study reported that when children drew pictures in response to their doctors' questions about their migraines, the doctors were able to tell the difference between migraine and nonmigraine headaches in the majority of cases.
Symptoms in Children. The standard diagnostic criteria for migraine in adults, however, may apply to only about two-thirds of migraines in children and adolescents. For example, the following differences have been observed:
- Headaches tend to last for a shorter time (as little as an hour) in children.
- Migraine tends to occur in the front of the face and occurs on both sides in two-thirds of child patients.
- Children may often have a form of migraine known as a migraine equivalent or abdominal migraine, which does not cause a headache at all. Instead children experience periodic bouts of nausea and vomiting (called cyclic vomiting syndrome) or other secondary symptoms found in adult migraine, such as a reaction against light or sound. Cyclic vomiting may actually occur in nearly 2% of school-aged children with or without a migraine association.
- Migraine triggers in children are similar to those in adults, but common ones in children are eating ice cream and anxiety and fear.
Outlook in Children. Migraine in children is disabling, as it is in adults, and they tend to lose more school days than other children. Children with frequent headaches may also be at higher risk for headaches in adulthood and also for other physical and psychiatric problems.
Treatments in Children. For most children with migraines, mild pain relievers and home remedies may be sufficient.
- The standard approach for migraine in children is to start with ibuprofen (Advil) or acetaminophen (Tylenol) as early as possible. An oral form is recommended but if the child is vomiting, then rectal administration may be used.
- Ginger tea or ginger ale may be helpful and soothing.
In severe cases, more potent agents are used. Some options include the following:
- Dihydroergotamine has been an option for children with severe migraine.
- Non-oral forms of triptans, such as the sumatriptan nasal spray, may prove to be safe and effective in children, although a 2000 study showed effectiveness in only one in 10 adolescents. (Studies on oral sumatriptan have not shown it to be at all effective in children.)
- Intravenous prochlorperazine may be effective in stopping intractable migraines in children.
- For prolonged headache, dexamethasone (an inhaled corticosteroid) may provide relief by reducing inflammation.
Preventive Measures in Children. Non-medication methods, including biofeedback and muscle relaxation techniques may be helpful. In one study of children with migraines and poor sleep habits, instructions in improving sleep without using medications reduced migraine attacks significantly.
If these methods fail, then preventive drugs may be used, although evidence is weak on the effectiveness of standard migraine preventive agents in children. Flunarizine (Sibelium), an anti-seizure agent that also blocks calcium channels, has been effective for children in trials but is not yet approved in the US. The tricyclic antidepressants have been useful for childhood migraine with cyclic vomiting.
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Withdrawing from Medications
If rebound migraines develop because of medication overuse, the patients cannot recover without stopping the drugs. (If caffeine is the culprit, a person may only need to reduce coffee or tea drinking to a reasonable level, not necessarily stop drinking it altogether.) The patient usually has the option of stopping abruptly or gradually and should expect the following course:
- Most headache drugs can be stopped abruptly but the patient should be sure to check with the physician before withdrawal. Certain non-headache medications, such as anti-anxiety drugs or beta-blockers, require gradual withdrawal.
- If the patient chooses to taper off standard headache medications, withdrawal should be completed within three days or shorter. Otherwise the patient may become discouraged.
- Alternative medications may be administered during the first days. Examples of drugs that may be used include dihydroergotamine (with or without metoclopramide), NSAIDs (in mild cases), corticosteroids, or valproate.
- Whatever approach is used for stopping medication, the patient must expect a period of worsening headache afterward. Most people feel better within two weeks, although headache symptoms can persist up to 16 weeks (and in rare cases even longer).
- If the symptoms do not respond to treatment and cause severe nausea and vomiting, the patient may need to be hospitalized.
On the encouraging side, some patients experience dramatic long-term relief from all headaches afterward, and one study reported that 82% of patients significantly improved four months after withdrawal.
Drugs Used for Treating Migraine
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Drugs
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Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin, ibuprofen (Advil), and naproxen (Anaprox, Aleve).
Potent prescription NSAIDs are available.
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Used as first line for mild to moderate migraines.
Disadvantage: Most NSAIDs are not effective alone for severe migraines. Gastrointestinal problems, including possible bleeding, with long-term use.
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Excedrin Migraine (contains acetaminophen, aspirin, and caffeine.)
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Over-the-counter medication proven to be effective for temporary relief of migraine.
Disadvantage: Not usually effective for severe migraine.
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Triptans.
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First choice for moderate to severe migraines. Sumatriptan is the oldest and least expensive. Newer ones have fewer side effects and a lower risk for recurrence, however, and may prove to be more cost effective.
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Ergots: Ergotamine, dihydroergotamine (DHE), methysergide.
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Most forms are less effective and have more severe side effects than triptans. Role is now uncertain, although intravenous ergots still beneficial for severe migraines.
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Lidocaine.
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Nasal drops may be effective in 15 minutes. Limited evidence on effectiveness.
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Anti-nausea Agents: Oral agents include metoclopramide (Reglan), domperidone (Motilium). Intravenous agents include prochlorperazine (Compazine), droperidol (Inapsine), chlorpromazine (Thorazine).
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Oral combination of NSAIDs and metoclopramide effective in treating migraine. Oral forms of metoclopramide or domperidone reduce nausea and may help absorption of migraine agents. Intravenous administration of prochlorperazine, chlorpromazine, or droperidol useful as rescue treatment for severe prolonged attacks in some patients. Note: Droperidol has been associated with life-threatening heart disturbances.
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Butalbital (a barbiturate) plus other compounds including aspirin and caffeine (Fiorinal, Issocet, Endolor, Femcet) or acetaminophen (Phenilin, Axocet, Bucet, Fioricet).
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Has some benefits for acute attack but has no proven advantages over other agents. Can become habit forming over time.
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Corticosteroids (dexamethasone, hydrocortisone).
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Rescue therapy for patients with status migrainous.
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Opioids (oral or nasal spray [Butorphanol]).
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For rescue treatment in very severe pain that does not respond to other agents.
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