Headache Help (10 page)

Please note: For most headache medications, particularly the “as-needed abortives,” the generics do not work as well as the brand names. Although generics contain the same compounds as brand names, their binders and other substances are often less effective. As a result, brand-name medications may be absorbed into the bloodstream more thoroughly.

FIRST-LINE MEDICATIONS FOR ABORTING MIGRAINES

1. T
RIPTANS

The triptans have revolutionized the treatment of migraines. Doctors now prescribe fewer preventive medications than in the past because the abortive triptans are more effective. These medications, which include Imitrex, Maxalt, Amerge, Zomig, and Relpax, ease headache pain without causing excessive drowsiness, nausea or stomach problems, addiction, or difficulty in thinking. These medications work by raising the level of serotonin in the brain and thereby reducing dilation of the surrounding blood vessels. They often lift the headache away, rather than simply covering over the pain. That’s why many people describe triptan as a “miracle medicine.”

Triptans are effective for about 65 percent of migraine sufferers. However, people who have more than minimal risk factors for hardening of the arteries should generally avoid them. These risk factors include: poorly controlled high blood pressure, strong family history of coronary artery disease or heart attacks, diabetes, high cholesterol, smoking, male gender, or older age ranges. In general, doctors use these medications with caution, although they have been deemed safe under most circumstances. They should not, however, be used if you’re pregnant or nursing.

So far, six triptans have been approved, and more are on the way. Like NSAIDs, these medications have many similarities but also important differences. Amerge, for example, tends to have fewer side effects, while Imitrex gives more relief to more people; Maxalt tablets work faster than other triptan tablets, while Imitrex Nasal Spray or injections are the fastest. So even though these medications are quite similar in safety, if you don’t tolerate one of them, you can try another and have a pretty good chance of finding one that is appropriate.

It may be worthwhile to try two or even three types of these medications before giving up on the triptans.

• S
  UMATRIPTAN
  (I
  MITREX
  )
  Imitrex is the gold standard in migraine abortives. It was the first triptan developed and used, and it has been given to over 15 million people worldwide. It is available in nasal spray, injection, and tablet form, with tablets the most convenient. If you have severe nausea, however, you may prefer the nasal spray or injections. The nasal spray is slightly milder than the tablets but is quickly absorbed and works somewhat faster than the tablets. The injections are somewhat more difficult to use but faster-acting and more effective than virtually any migraine-abortive medication.
  TYPICAL DOSE
  : One tablet (50 mg) every two to four hours as needed, four per day at most. Some people use 25 mg (half a 50 mg tablet or a 25-mg tablet), and some people use 100 mg at a time. While the average dose is 50 mg, doctors try giving just half a tablet the first time a person uses a triptan to see what the effect will be. This way, side effects, if any, will be minimal.
      Imitrex Nasal Spray is available in 5-mg and 20-mg sizes. Each spray dose is for one-time use only. Most patients need the 20-mg spray. The usual dose is one spray every three to four hours, as needed, two per day at most. Imitrex Nasal Spray is usually considered about equal to the tablets, both in strength and efficacy. Side effects are similar with the tablets and the spray.
      You should limit the nasal spray to two 20-mg sprays per day at most, separating them by at least two hours. Only one spray and two tablets at most should be used in a single day.
      The nasal spray is easy to use, and its instruction sheet is easy to follow. Basically, you should keep your head in an upright position, close one nostril, insert the nozzle of the nasal spray into the open nostril, and press the blue plunger on the Imitrex. The nasal spray, of course, allows for much more convenient dosing than the injection. It is usually sold in a box containing six sprays. The spray is well tolerated but can leave a bad taste in the mouth. Keeping the head upright can help. Sucking on candy or drinking juice or pop may also help offset the bad taste.
      The injectable form (subcutaneous) is the most effective migraine abortive for severe, fast-onset migraines. The usual dose is one injection every three to four hours, as needed, two in one day at the most. The injections can be used in the same day as the tablets or the nasal spray; one tablet is equal to one nasal spray, and approximately two tablets or two nasal sprays equal one injection. The usual limit is ten tablets per week, ten sprays per week, or five injections per week at most. Habitual use at this level is not recommended, however.
  SIDE EFFECTS
  : Tightness in the muscles, particularly in the throat, chest, or jaw, may occur. If you experience more than mild chest heaviness or muscle tension in the chest muscles, you should probably discontinue using a triptan. Occasionally, a triptan is retried after a cardiac workup has been done. Serious heart side effects, though extremely rare, have been reported with Imitrex and the other triptans. Tingling in the fingers or toes, sedation, a rash, shortness of breath, or “spaciness” are also side effects linked to the triptans. These side effects tend to be short, usually lasting no more than one hour. Occasionally, however, side effects may last longer. Many people do not experience any side effects at all.
  TRIPTANS WITH OTHER MEDICATIONS
  : The ergotamines should not be used in the same day, nor should one triptan be used in the same day as another triptan. Pain medications (Fiorinal, Vicodin, codeine) may be used in the same day or even at the same time as a triptan. Antiemetics (antinausea medications), such as Phenergan, Reglan, or Compazine, are safe with triptans.
  
• R
  IZATRIPTAN
  (M
  AXALT
  )
  Maxalt is a well-tolerated triptan available either as a tablet to swallow or a dissolving tablet to put on your tongue. The dissolving tablet, Maxalt MLT, has a slight minty taste and does not require any water. Maxalt has a similar profile to Imitrex, with approximately the same effectiveness.
  TYPICAL DOSE
  : One tablet, 10 mg, may be taken every three to four hours as needed, three in a day at most. You should limit the tablets to no more than ten tablets a week. Maxalt MLT tablets have the same instructions as the tablets you swallow. Maxalt can take anywhere from 20 minutes to two hours to help.
  SIDE EFFECTS
  : Side effects are very similar to those of Imitrex. These include nausea, chest heaviness or pressure, pressure in the throat, shortness of breath, rash, tingling sensation, particularly in the fingers, heat sensation, tiredness, drowsiness, and dizziness. However, as with Imitrex, most of the side effects, should they occur, are brief. If they are more than mild, Maxalt should not be taken again. Caution is recommended for people who have more than minor risk factors for heart problems.
  MAXALT AND OTHER MEDICATIONS
  : The same restrictions apply as to Imitrex. It should not be used in the same day as ergotamines or other triptans.
  
• N
  ARATRIPTAN
  (A
  MERGE
  )
  Amerge is very similar to Imitrex, but its effect lasts longer. It’s considered the “kinder, gentler triptan.” It takes longer to work, but tends to give relief all day. While Amerge is available in 1-mg and 2.5-mg strengths, the vast majority of people need 2.5 mg per dose. Amerge and other long-acting triptans are sometimes used in specific situations to prevent headaches (such as for menstrual migraines). Amerge is best for slower-onset, more moderate migraines. Imitrex, particularly the nasal spray or injections, may be a better choice for severe, fast-onset headaches with moderate to severe nausea.
  TYPICAL DOSE
  : One tablet every three to four hours as needed, two in a day at most. Most people only need one tablet. The very first time you use Amerge, try a half tablet to see how you will react to it.
  SIDE EFFECTS
  : The side effects are very similar to those of Imitrex and Maxalt, but Amerge is usually tolerated better. Amerge may be taken in the same day or even at the same time as pain medications (such as aspirin, ibuprofen, Fiorinal, Vicodin, Tylenol). However, do not use ergotamines (Cafergot pills or suppositories) or other triptans in the same day.
  
• Z
  OLMITRIPTAN
  (Z
  OMIG
  )
  Zomig is another in the growing list of triptans. The usual dose is 5 mg every three to four hours, as needed, two per day at most. Zomig is also available in a 2.5-mg tablet. Zomig has the same general tolerability and efficacy profile as the others. Like the other triptans, Zomig may have short-lasting side effects.
  
• E
  LETRIPTAN
  (R
  ELPAX
  )
  AND
  F
  ROVATRIPTAN
  These are newer triptans, available in tablet form. More clinical experience is needed to determine what role these newer triptans will play.
  

2. N
ONSTEROIDAL
A
NTI
-I
NFLAMMATORIES
(NSAIDS)

These are very useful nonsedating medications if you don’t become nauseated with a migraine. If one of these anti-inflammatories doesn’t help, try another. It may be worthwhile to try two or even three types before you move to something else. If you’re over age fifty, however, chances are your doctor will not recommend these drugs, because as you get older, you become more sensitive to these drugs’ gastrointestinal side effects. A newer class of NSAIDs (Celebrex, Vioxx), however, has fewer gastrointestinal side effects.

    The NSAIDs (naproxen, ibuprofen, ketoprofen—all available over the counter) are discussed in detail in Chapter 2. The typical doses and side effects listed there also apply to migraines.

• N
  APROXEN
  (A
  LEVE
  , N
  APRELAN
  )
  :
  This OTC medication is a very effective, nonsedating medication, but unfortunately often causes stomach upset, especially in people over forty. It is particularly useful for menstrual migraines and is commonly used as a preventive medication (see Chapter 6). Aleve is available over the counter in 220-mg tablets. Prescription naproxen is available in a variety of doses, from 250 mg to 550 mg. Taking it with coffee or a caffeine tablet may enhance its effectiveness. Naprelan is an excellent, long-acting form of naproxen.
  TYPICAL DOSE
  : Two Aleve (440 mg total) with food to start. If you do not experience any significant nausea, repeat in one hour, and then at three- or four-hour intervals, taking six per day at most.
  SIDE EFFECTS
  : Nausea and stomach upset, especially among older people. With long-term daily use, liver, kidney, and gastrointestinal problems are a concern. Metoclopramide (Reglan), a medication for nausea, may help offset the side effects and increase the effectiveness of naproxen.
  
• I
  BUPROFEN
  (
  AVAILABLE OVER THE COUNTER IN
  200-
  MG TABLETS AS
  A
  DVIL
  , N
  UPRIN
  , M
  OTRIN
  )
  Ibuprofen is not as long-lasting as Aleve, but some people find it as or more effective. The usual dose is two or three tablets with food every three to four hours as needed, with the total dose not exceeding 2,400 mg per day. Adding caffeine, either by coffee or in pill form, often enhances its effectiveness. Stomach upset is fairly common.
  
• K
  ETOPROFEN
  (O
  RUDIS
  KT)
  This over-the-counter anti-inflammatory is available in 12.5-mg doses. The usual dose for a migraine is two or three tablets with food every three to four hours, as needed. Eight tablets per day is the maximum. As with ibuprofen and Aleve, stomach upset is relatively common. Taking it with caffeine may increase the effectiveness.
  
• C
  OX
  -2
  INHIBITORS
  (V
  IOXX
  , C
  ELEBREX
  )
  These newer anti-inflammatories are the first ones not to cause stomach upsets and ulcers as the other anti-inflammatories often do. So called because they block an enzyme called Cox-2 that triggers pain and inflammation, these drugs are popular for arthritis, menstrual pain, and other acute pain. They are being studied to determine their effectiveness for headaches. Although Cox-2 inhibitors are deemed safe and are used by millions of people, one recent study raised questions about their safety in a very few older patients. Their safety, therefore, has not been definitively established.
      If you take a Cox-2 inhibitor, do not take another anti-inflammatory such as Advil, aspirin, or Aleve. However, a Cox-2 inhibitor can be utilized with low-dose aspirin if you take aspirin for prevention of stroke or heart attacks. Tylenol is OK as well. People who have had reactions to sulfa antibiotics should not take Celebrex. Vioxx is particularly good because it is long acting and indicated for acute pain. The usual dose is 12.5 or 25 mg (tablets) every four hours, as needed, 50 mg in one day at most. If used daily, it should be limited to 25 mg per day.