Migraine Headache Treatments
A large number of patients with migraine do not see a physician. They take over the counter pain medications and simply suffer with their headaches. Prior to the 1990’s, the prescription medications available for migraines were either not very effective or narcotics, which are potentially addicting and make people drowsy The 1990’s brought a revolution of treatment for migraine headaches with the release of a new class of medication, the triptans. The triptans are available in multiple forms including tablets, nasal spray, and subcutaneous injection and all are extremely safe. They are clearly more effective than the medications that were previously available for migraines. With theses medications, we began to look not just headache symptom relief or headache pain relief, but rather total treatment of migraine symptoms including nausea, light and noise sensitivity, as well as sinus symptoms and neck pain. Patients with ischemic heart disease should not use triptans.
How Can I Help My Doctor Help Me
Having accurate counts of all of your acute headache medications is essential to good headache care. Dr. Loftus designed iHeadache (an iPhone and iPod Touch app) to do this. This program also tracks disability and symptoms to aide in proper diagnosis of your headaches.
What is a triptan?
Imitrex® (sumatriptan) was the first triptan brought to market. Imitrex is available as an injection, nasal spray, and tablet. The injection is associated with the highest incidence of side effects, which can be annoying but are quite transient. Another problem with the injection is its relatively high price however; sumatriptan injection is now available in generic form. The tablet is the most convenient, easiest, and commonly used form of Imitrex however the injection is clearly the fastest migraine reliever on the market. An alternative to both the injection and tablet is the Imitrex nasal spray, which sometimes works faster than the tablet. The sumatriptan tablet is also generically available. The combination of Imitrex with an NSAID is called Treximet® and is now available. It is clear the combination of Imitrex with naprosyn works better than either by itself. In addition, multiple vendors are looking at bringing various patch forms to the market. There are also needless systems coming to market as well.
The only other triptan offered in multiple forms is Zomig® (zolmitriptan) which comes in a tablet, dissolving tablet and nasal spray. The tablet and dissolving tablet are of equal efficacy with nearly identical times of onset for headache relief. By comparison, the Zomig nasal spray has an onset that is significantly faster than either Zomig tablet but not as fast as the Imitrex injection. The nasal spray may be effective in patients who do not respond to the tablets. Studies of the nasal spray included patients who were potentially already using Zomig® tablets and this may have biased the results. Without head-to-head data using patients who have never used triptans it is impossible to say with certainty which drug works faster.
The other triptans on the market; Amerge®, Axert®, Frova®, Maxalt® and Relpax® are only available in tablet form. Maxalt®, like Zomig® comes in a dissolvable. It is important to note that the dissolvable form is not absorbed more quickly into the bloodstream than the oral tablet.
The oral tablets are divided into two groups, the fast acting and slower acting. The faster acting group includes Axert®, Imitrex®, Maxalt®, Relpax® and Zomig®. The slower acting group includes Amerge® and Frova®.
The following table shows a comparison of the various triptans, the formulation that is available and their consumer characteristics.
|Name||Formulation||Desirable Characteristics||Other Characteristics|
|Imitrex®||Injection||Fast acting; highest response rate, generic||Most expensive; most painful.|
|Nasal spray||Good for oral vomiting; works a little faster than tablets.||Twice the price of the tablet.|
|Tablet||Good response to headache for lower cost. All fast acting tablets are similar in groups of patients but individual patient response may vary from drug to drug. Imitrex is now generically available.||Other options work faster but will cost more.|
|Tablet||Last longer than faster acting tablets.||Does not work as fast.|
|Dissolvable Tablet||Does not require water to swallow.||Does not work faster than regular tablet.|
Patients not currently satisfied with their current migraine treatment have preferred the triptans. They have also been shown to be cost effective. A typical response for the fast acting tablets will be substantial pain relief in less than 2 hours. The Imitrex injection can begin working in less than 15 minutes. Occasionally, the triptans are used in migraine prevention where the trigger is clearly identified and predictable such as with menstrual cycles for example. Triptans do not work when the headaches are daily and work much less effectively when the headaches are nearly daily.
Which triptan should I use?
The answer is relatively simple. Patients should use the triptan that works best for them. In Dr. Loftus’ practice, if a fast acting triptan is being prescribed, he gives the patient a couple of sample tablets of each of the triptan medications to try on different headaches.
Despite what others will claim, Dr. Loftus does not believe that any of the fast acting oral triptans can claim superiority to any other oral triptan medication. The studies demonstrating Relpax® to have superiority to other oral triptans have several design flaws. The most significant, in his opinion, is the inclusion of patients who previously used competitor's medication in the study. He has reviewed the Relpax® versus Encapsulated Sumatriptan studies in detail. Both current Imitrex® users who would probably actually favor Imitrex®, and prior users who would favor Relpax® are included. In addition, the Sumatriptan used has never been shown to be bioequivalent to brand name Imitrex® in migraine patients. The company and author have data that could address some of these concerns but will not share it.
Cambia® is the only NSAID that is FDA approved to treat migraine. Its cost is in the same ballpark as the non-generic triptans. It has none of the typical triptan side effects so it is also an excellent therapy for those patients who cannot tolerate triptans for safety reasons. Cambia should be avoided in those patients that cannot tolerate or are told to avoid NSAIDs. Although no acute treatment is FDA approved for chronic migraine, NSAIDs like Cambia have been shown to continue to have efficacy in these types of patients where triptans tend to lose their efficacy.
Migralex® is a unique aspirin and magnesium combination that can be useful in migraine. Although not as likely to be effective triptans and cambia, for those patients in whom it works, it is a very inexpensive therapy and not associated with the potential of medication overuse headaches.
DHE related medications
For patients who do not respond to triptans, cambia, or migralex above, There is a group of medications based upon dihydroergoatmine (DHE). These medications, like the triptans, should not by someone with ischemic heart disease. Currently, most patients use the nasal form of DHE called Migranal®. The response of the migraine to Migranal® is similar to the fast acting oral agents. Similar to the triptan drugs, Migranal® treats the entire migraine and its accompanying symptoms. It also seems to work well for patients who have failed multiple prior triptans. The only significant side effect is some nasal stuffiness. Injectable DHE is less expensive than nasal DHE but requires the patient to self-inject the medication. Inhaled DHE (formerly known as Levadex) will hopefully be available soon. It should be as effective as MIgranal without the nasal stuffiness. The cost of this treatment relative to injectable DHE and nasal DHE is not known.
Are triptans safe?
The triptans should not be used in patients with ischemic heart disease. All of the oral triptans cause approximately 5% of contraction of the coronary artery vessels. This is obviously not significant to patients unless a large percentage of the vessel is blocked by an obstruction in the artery known as a plaque. If any testing should be performed, each physician individualizes it for his or her patient. It should be noted the primary cause of heart attack in the age group of migraine patients is from plaque rupture, a sudden opening of the plaque and clot formation, and not from a slow narrowing of the artery.
Sphenopalatine Ganglion Block (SPG block)
SPG block is now possible using a device that is placed by a physician througth the nose. One of these devices is Allevio™. With this device, lidocaine, a local anethetic is used to produce the block. It also blocks the 2nd branch of the trigeminal nerve. This treatment not only treats an acute headache but appears to help prevent future headaches. There is limited controlled data at this time. Most insurances will pay for this therapy at this time. This therapy can safely be done during pregnancy. Bellaire Neurology currently offers this therapy to patients.
For those willing to travel to Canada or Europe, Gammacore® is an electronic device that delivers current to the Vegas Nerve. A smallopen label study by Peter Goadsby indicates that this device has benefit for migraine. A controlled study is currently underway and hopefully this device will be approved soon.
Data: Goadsby P, Non-invasive Vagus Nerve Stimulation (rVNS) for Acute Treatment of Migraine: An open label pilot study -presented 65th Annual AAN meeting, San Diego, California, USA.