In part one of this series, I reviewed the over-the-counter options for migraine relief. For some of you, these may represent a viable choice in certain situations.
For others, not so much.
That’s where the prescription medications come into play, which is the topic of today’s post.
Up until quite recently, there wasn’t much difference between the over-the-counter and prescription medication options for migraine relief. On the whole, prior to the 1990s, the available prescription options stunk.
With the introduction of Imitrex in 1991, things changed quite a bit. I still remember the day my mom came home ecstatic after she’d pulled over on the side of the road and injected herself with her first ever dose. The advent of the triptan era was a huge moment for her, as it was for many other migraineurs. For many, it was the first thing they’d every taken that could end a full on migraine. The first migraine miracle.
Prescription Medications for Migraine Relief
We can further divide of prescription medications for migraine relief into those that are specific for migraine, meaning they work specifically on the pain mechanisms that underpin migraine (and generally aren’t any good for other types of pain), and those that are not. The ones that are not are really just general, all purpose pain remedies that require a doctor’s blessing.
Non-Specific prescription remedies:
1. Morphine derivatives – Hydrocodone, Oxycodone, Codeine; usually combined with Acetaminophen or Aspirin (brands include Vicodin, Lortab, Percocet, Tylenol 3, etc.)
- Effectiveness against migraine: 4. Typically only beneficial if taken early in the course of a headache; otherwise, while it may dull the senses for a few hours or perhaps knock you out cold, it will often be followed by a headache of even higher intensity.
- Side effects: includes somnolence, cognitive impairment, liver toxicity, physiological tolerance and dependence, worsening of migraines (and other types of chronic pain) over time. Emerging evidence also indicates that opiates, when taken frequently, end up worsening the chronic pain syndromes they are designed to treat (including migraine) over the long term.
- Potential for rebound headaches: Very high
[message_box color=”blue”] THE VERDICT: A very poor choice for migraine relief in most cases: marginally effective, with a high risk of ultimately worsening any chronic pain issue. For these reasons, the American Academy of Neurology cautions doctors against prescribing them for migraine relief.[/message_box]
2. Combination medications with Caffeine and Butalbital (Fioricet, which also contains Acetaminophen, and Fiorinal, which also contains Aspirin)
- Effectiveness against migraine: 5. Typically beneficial if taken early in the course of a headache. In the occasional migraineur will abort a more intense headache.
- Side Effects: can include liver toxicity, stomach upset, bleeding tendency (if there’s Aspirin), sedation, balance problems, memory impairment, physical tolerance and dependency, insomnia
- Potential for rebound headaches: off the charts
[message_box color=”blue”] THE VERDICT: In general, it’s hard to ever justify using these over the over-the-counter combination pills (which should only be used sparingly themselves). They differ only in the addition of the butalbital, a sedative that, beyond making you drowsy and impairing cognitive function, likely confers an even greater risk of rebound headaches without any clear extra benefit against migraine. In other words, these are like taking Excedrin, just more dangerous.[/message_box]
3. Fast Acting Triptans – Sumatriptan, Rizatriptan, Zolmitriptan, Almotriptan, Eletriptan (brands Imitrex, Maxalt, Zomig, Axert, Relpax)
- Effectiveness against migraine: 8.5. Very effective when taken early in the course of a headache, but for many will still work taken well into a migraine. Also available as a nasal spray and by injection, which is particularly helpful for those with nausea and vomiting with their migraines.
- Side effects: most common is tightness in the neck, shoulders, and jaw; fatigue. Also not recommended for those with uncontrolled blood pressure, or vascular disease, due to a theoretical increase in the risk of vascular events (stroke, heart attack) in these populations
- Potential for rebound: High
[message_box color=”blue”] THE VERDICT: Overall, the triptans are generally light years ahead of the other available prescription remedies, and are going to be the best choice for majority of folks whose migraines don’t respond to over-the-counter options (I personally would never take any other prescription medication for mine). However, they aren’t without some unpleasant side effects, and do carry a significant risk for rebound headaches – all the more reason to make sure you don’t need to use them more than once in a great while.[/message_box]
4. Long Acting Triptans – Frovatriptan, Naratriptan (brands Frova, Amerge)
- Effectiveness against migraine: 5. These long acting triptans aren’t particularly good at ending an ongoing attack, thanks to their slow onset of action. However, in specific cases, they can be useful for migraine prevention when taken on a very short term basis. These days, their main raison d’etre is for women whose migraines occur almost exclusively during menstruation. In this case, they’re typically taken every day for five days, beginning 2 days prior to the anticipated onset of menstruation.
- Side effects: most common is tightness in the neck, shoulders, and jaw; fatigue (though typically less intense than the short acting triptans). Not recommended for those with uncontrolled blood pressure, or vascular disease, due to a theoretical increase in the risk of vascular events (stroke, heart attack) in these populations.
- Potential for rebound: moderate to high (less than their short acting cousins above)
[message_box color=”blue”] THE VERDICT: Generally a poor choice for relieving an ongoing migraine, but useful in certain contexts for migraine prevention (on a very short term basis).[/message_box]
5. Dihydroergotamine – DHE (brand Migranal)
- Effectiveness against migraine: 7. Not quite as effective as the triptans at alleviating migraine, but pretty much better than most everything else. Available as a nasal spray and injection (oral causes too many side effects).
- Side effects: many potential side effects, due to the fact that they interact with many chemical receptors. Nausea is common. Rare serious cardiac side effects are also associated (including potentially fatal abnormal heart rhythms)
- Potential for rebound: high
[message_box color=”blue”] THE VERDICT: Pretty good at relieving migraines; however, given their high side effect potential there are only rare cases where DHE would be used over a triptan[/message_box]
Prescription Medications: The Final Summation
As I said, prior to the introduction of the first triptan, Imitrex, in the 1990s, the prescription options for migraine relief basically stunk. And, to this day, the options beyond the triptans still mostly stink. This is because they either work poorly against migraine pain, are fraught with potential dangers, or both.
In the final post in this series, I’ll provide a simple, easy to follow protocol that I use (for most of my patients) for choosing the most appropriate agent for any given migraine.