Difficult Migraine patients in whom the gold standards of care for their symptoms are contraindicated may still have several treatment options.
Some of the contraindications for triptan and ergotamine use include:
- Cardiovascular disease
- Cerebrovascular disease
- Peripheral vascular disease
- Uncontrolled high blood pressure
- Drug interaction potential
- Drug intolerance
Patients who are in this predicament often go to other patients and advocates asking the question “How can we treat my Migraines since I can’t use triptans or ergotamines?”
Fortunately, there are several options. When the proactive patient educates themselves about these options sufficiently that they can speak knowledgably to their doctor, they’ll find themselves less likely to be told “There’s nothing I can do for you anymore.”
NSAIDs treat both pain and the inflammation that plays a major role in Migraine attacks and they’re often used both singly and in concert with other treatments for optimized effectiveness. Piroxicam is the longest acting of the NSAIDs and may be more helpful to patients with long-standing pain or attacks, or in those with a problem of frequent recurrence. Like all drugs, NSAIDs have problems too. These include decreased clotting ability and toxicity to kidneys and hearing. Patients on NSAIDs are often cautioned to take special care of their digestive system and stomach, as spontaneous bleeding can sometimes occur and should be considered an emergency situation. There is an increased risk of cardiovascular disease as well as a propensity for patients on long-term or repeated therapy to suffer medication overuse headache.
Steroidsfight the inflammatory processes that may play a part in Migraine attacks and can be used alone or in concert with other medicines. There is no immediate pain relief associated with steroid treatment, but if the reduction in inflammation is sufficient to stop the Migraine attack, the pain too will cease. There are several types of steroids, and treatment ranges from an injection during a Migraine attack, to a taper of three to six days, to an IV bolus of high dose steroids followed by a taper that may last a month or more. There is unfortunately not a lot of written evidence for the use of steroids, but it is often worth a try to help break an especially intractable attack. It’s suggested that steroids not be given more than three days per month, and since they create problems with blood sugar fluctuations in diabetics, should be used only with special caution in these patients. Those with digestive or stomach problems often should take precautions to protect themselves, as steroid use can sometimes cause bleeding that should be considered an emergency.
Neuroleptics target dopamine — a neurotransmitter implicated in the Migraine process. Symptoms that might imdicate a hypersensitivity to, or surge in dopamine levels include yawning, mood changes, nausea and vomiting, lightheadedness and restlessness. Neuroleptics affect dopamine, and are often used in Migraine and other conditions to help control nausea, vomiting and to relieve gastric stasis as well as the Migraine attack itself. These drugs can be used alone, but when used in concert with other medicines, the combination is often more effective than the combined strength of either of the two medicines alone. There can be significant and rarely permanent side effects with long-term usage of these drugs of which patients should be made aware. It’s wise for patients to talk to their doctors about the associated risks of prolonged use. Additionally, it’s becoming more recognized that, in rare cases, use of this drug even a single time can result in permanent side-effects. Side effects patients will want to discuss include: tardive reactions, sedation, movement disorders, prolonged heart QTc interval, and metabolic syndrome.
Miscellaneous. Some drugs are used both to prevent Migraine as well as treat an attack. Examples include: intravenous magnesium and/or valproic acid which may be effective after a single dose, or may require up to 5 doses 24 hours apart. Intravenous levitiracetam has little written evidence for its use with oral gabapentin, but there has been some success with the combination and it may be an option for some patients. Intravenous Benadryl is sometimes used alone or in combination with other treatments and can be helpful in aborting a Migraine attack. Butterbur (petasides) is over the counter, and has also had some success when used as an abortive, although it is usually known for its effectiveness as a preventive. Feverfew also has some evidence that it is effective as an abortive as well as a preventive. Care should be taken as it can cause severe reactions when taken with other Migraine medicines. It should never be taken during pregnancy. Capsaicin nasal spray is initially painful for a few moments. Despite that, it is helpful for some patients and is a natural remedy that requires no prescription. Lidocaine nasal spray is sometimes helpful for certain patients, as are lidocaine patches. Midrin is a combination therapy that has been removed from use in the United States, however a Midrin equivalent is still available although it is unknown if it will remain so for very long. Midrin contains a drug that constricts blood vessels, and may remain contraindicated for some patients in which triptans or ergotamines are contraindicated. Caffeine alone or in combination with other treatments can trigger Migraine in some patients, but in others it can help to abort the attack. It’s easy to find and take, but it can sometimes lead to rebound and is often only effective in patients who do not consume daily caffeine. Peppermint oil can be soothing during an attack and act both as a cooling pain relieving agent to the skin, but also as aromatherapy. Periactin is sometimes helpful in children with Migraine as a preventive or an abortive. A TENS unit helps to lower the sensation of pain by overloading pain circuitry, and may be helpful for some patients.
Opioids are generally not considered a wise choice for most Migraineurs because of the risk of medication overuse headache (MOH) and the progression/chronification of Migraine to a more serious, difficult situation to treat, as well as the potential for abuse/misuse. Migraine isn’t a pain disorder but a neurological disorder of which pain is only a single component. Medicines that more specifically target the neurologic processes tend to be more effective. As a result, many physicians are beginning to refuse opioid treatment to their patients. If you ever have the need or desire for opioids to treat your Migraine attacks, this is a good topic of discussion for your next office visit. Opioids should not be a first choice treatment, but instead only used when other options are not available. Having an opioid treatment plan in place with your doctor before you need it is an option Migraineurs may want to take advantage of.
for symptomatic relief include placement of peripheral stimulator devices in occipital and supraorbital regions of the head. These techniques are still investigational and have not yet been FDA approved for Migraine. Currently they are being used only in chronic Migraine patients.
— Developed by a United States company and already in use in Europe, the transcranial magnetic stimulator is enjoying success overseas, yet still awaits FDA approval for use here in America. Powerful magnetic pulses help to abort the Migraine process and may someday be an option for those who are unable to utilize other treatments.