How Can we Treat my Migraines Without Triptans or Ergotamines?

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

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.

Steroids

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

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

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.

Surgical procedures

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.

Coming soon

— 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.

Read more about treating migraines without triptans or ergotamines in Part 2

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.
View References
Nahas, Stephanie J., MD, MSEd. “Symptomatic Treatment Options when Triptans and Ergots are Contraindicated.” American Headache Society’s Annual Scientific Meeting, 2012.

Comments

View Comments (9)
  • Newdancerco
    5 years ago

    I get frustrated by the assumption that Triptans and DHE are the “right” treatment for migraine, and that the use of opiods is “inappropriate”, or in your words “not considered a wise choice”.
    I say this as a chronic migraine sufferer who when chronic using every single Triptan available, one by one, as well as all the other adjuncts (including topamax 300+mg per day, which I quit over 5 years ago but still have word problems from). As directed by my neurologists-ALWAYS.

    Opiates suck-they are addictive and only cover the pain. But I’m willing to take that for some rest.

    And when even the PATIENT community is saying that they should be removed from the toolbox, well, it makes me think people don’t understand the concept of a toolbox anymore. It isn’t just for the screwdriver and hammer you use regularly- it is for the non-electric handdrill your dad used as a kid, too. You may not need it much, but it is a tool in your toolbox and you have it when you are almost done with a rush project and the power goes out. (My Dad actually has one, a very cool way to get the job done, by the way.)
    Please, please, please- don’t throw the handdrill out just because you have an electric drill. I KNOW triptans work for most people, but for those of us in the dark, without power, the handdrill is all that works.

    Until we KNOW what causes migraines, sometimes that old, sucky option is all that stands between us and oblivion. We THINK it is a nervous system problem, but a good doctir will admit they don’t KNOW. I’m letting them cut into my head at the first opportunity on a theory, a good one I hope, that burning the nerves to my head will stop the pain. You really think at that point I care if opioids are problematic? I have 1 medication I can take at home to get relief- an opiate. When you convince them to take it off the table, and the nerves grow back, what choice is left but oblivion?

  • Ellen Schnakenberg author
    5 years ago

    newdancerco,

    You’re right – it’s so frustrating when doctors tend to think like cooks instead of physicians. There is no cookbook for Migraine. We do know that Migraine is neurological, we just don’t have enough details. It is a multi-faceted, genetic, neurological disease, and living with it changes your life forever. For many patients, they never have to consider anything stronger than a tylenol when a once a year attack hits them. People like you and me, have to make choices about our lives every single day of our lives.

    I wrote this piece because I am a patient that cannot use “hammers and screwdrivers.” My comorbid conditions make treating my Migraines so complicated that most doctors have blown me off because they simply don’t know enough themselves about alternative treatments to triptans and ergotamines, that they get frustrated and send me on to someone else, who will also get frustrated.

    Frustration with this disease is something I understand. Desperation often leads to poor decisions however, and I want to encourage you to remember that there is so much hope for you and for me. I also want to re-print the section on opiate treatment, as I don’t think you understood at all what I was saying:

    “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.”

    At the end I even tell patients: “Having an opioid treatment plan in place with your doctor before you need it is an option Migraineurs may want to take advantage of.”

    Because of my comorbidities and cumulative and permanent side effects of the one medicine I was able to take these last 10 years or so, I recently had to go onto opioid therapy. I hope you get the chance to read my comments about it, because it has rung so very true with other patients. I know of no specialists who have ever suggested that opiates should be removed from the Migraine tool box. They just want to be sure patients are having the option to try everything else first. Did you know, a study showed that few Migraineurs (episodic or chronic) were using any preventives. When asked how many had EVER used them, less than half of episodic patients, and 65.9% of chronic Migraine patients had ever used a preventive. Many patients stop their preventives for unknown reasons, and others don’t respond or can’t take preventive treatments. Regardless of the reason why they may not be taking preventives, patients are desperate.

    Here is the link:

    Migraine, Advocacy, and Accepting Opiate Therapy http://migraine.com/blog/migraine-advocacy-accepting-opiate-therapy/

    My suggestion to you is to get to a Migraine specialist, as they have additional education and skills that other doctors don’t have. They stay current and deal with Migraine and the other 300 headache disorders each and every day. They have devoted their lives to patients like us. Going to one has changed the lives of too many patients for me to count. Here is a link that can help you find the closest one to you:

    Looking For A Migraine Specialist? http://migraine.com/blog/looking-for-a-migraine-specialist/

    There are so many preventive medications out there that it would literally take 25 years to try them all. Then there are combinations, herbal and natural/alternative treatments, and other treatments. The options are virtually endless for most patients. The new things getting ready to be released, are numerous, and very exciting, making there many other choices than oblivion. Personally, I’m trying desperately to hang on for those options, because getting worse is not an option for me.

    I know the procedure you’ve decided to use. This is of course your choice. But, if you haven’t seen a specialist (a neurologist is not a Migraine specialist, though many specialists are neurologists) then you are far from the end of the line. Surgery is a permanent option however, and most specialists are very concerned about surgery. A looooong critique in the journal Headache is something I wish patients could read, as it talks in great detail about some surgical procedures and their flaws. You can get better. You can get worse. Don’t feel pressured to cut into your body because the stigma of friends and family who don’t understand make you feel this is going to make them finally take you seriously. Do it because you think it is your BEST option.

    Lastly, the most important thing, is that you get help from a counselor or psychologist to help you add techniques to your toolbox to help you learn to live with Migraine. If you are feeling that you are in a crisis, please seek the help of people trained in helping you. There are plenty of free hotlines where you can go to talk to professionals who can help you. http://migraine.com/migraine-and-mental-health/migraine-and-mental-health-suicide/ This link is an EXCELLENT place to send others who don’t understand the connection between Migraine and neurotransmitters too.

    Hang in there hon. We are here to help support you. You are not alone. You are not the only one. No one is trying to take away the only relief you have found so far. We’re just trying to help you find something better. I think most patients would gladly take something better if they could figure out what it is. yes?

    Please keep in touch and let us know how you’re doing. If you go on to have the surgery, I hope you’ll consider going to our forums and talking about it so others who may be considering it might get a more personal perspective from someone who’s been there, done that. Here is a link to the forums: http://migraine.com/forums/

    ~Ellen

  • laalaa81
    6 years ago

    Thanks for the post Ellen it’s certainly given me plenty of food for thought. After 2 years with chroic daily migraine and very little treatment, all I seem to hear from health professionals is that they can do no more for me. I might accept this if they had actually tried more than a couple of treatments. I am a Triptan intolerant migraineur, when this was discovered I was placed on Topiramate of which I can only handle a low dosage and Gabapentin (neither of which have had any positive affect in the last year), then a course of DHE that was also unsuccessful and a nerve block that lasted a whole 5 hours. After this my neurologist told me there was not much else that he could do for me, so this article will give me plenty of ammo at my next appointment.

  • Ellen Schnakenberg author
    6 years ago

    laalaa81 – I am thrilled to give you ammo for a next appointment! Thank you so much for commenting. Good luck, and PLEASE do let us know how your next appointment goes. My fingers and toes will be crossed for you!

  • jhallmd
    6 years ago

    Ellen:
    I appreciate your inclusion of surgical treatment on the list of treatment options for “difficult” migraines. I would like to offer up a less-risky and more permanent surgical option – nerve decompression of either supraorbital, temporal, or occipital nerves. I have personally treated patients who were labeled “difficult” and whose headaches are now very easily controlled with routine preventative medications after surgery. The anesthesia risk from these surgeries is no different as that of a stimulator placement (which is the biggest risk of either procedure).

    Thank you, though, for a very comprehensive and detailed article.

  • michaelpowell
    6 years ago

    Ellen,
    I appreciate your thoughtful and interesting article. I wanted to mention a recent article in the Annals of Neurology 2012, 72: 559-563. Acid Sensing Ion Channel 1: A Novel Therapeutic Target for Migraine with Aura. It details the use of an old drug used in the treatment of hypertension “Amiloride” as a potential treament of intractable migraine. An interesting comment in this article is that this type of treatment may be useful for treating “triptan resistant” migraines. Hopefully this might spur interest in more research in this area.

  • Ellen Schnakenberg author
    6 years ago

    michaelpowell – I will see what I can do to get a copy of this as it does indeed sound interesting! I’m always interested in anything new on the horizon. Seeing anything helps us all keep hope alive 🙂

  • jimhagen
    6 years ago

    Ellen,
    I appreciate the effort and time taken for this and other articles written by yourself and others…
    There are several things which strike me in this article that you may want to think about…

    The first is the first three words that you use to start the article…

    Difficult Migraine patients

    How does that sound when you say it over and over…?

    It perpetuates the perception that we are difficult. I know that you mean “patients whose headaches are intractable and difficult to treat”. But you could just say that…

    The other one, like the last one, comes from doctors and is doctor speak…

    MOH – Medication Overuse Headache… In other words people with migraines are abusing something and that is why they are in pain…

    I think sometimes we need to think and meditate on the terminology that is used by doctors and ourselves…

  • Ellen Schnakenberg author
    6 years ago

    jimhagen – I do appreciate your perspective in my choice of words in this article. However, I believe that when used in context they are still appropriate, and as such I do stand by them. As a chronic Migraineur myself, I would of course never want to offend anyone with any choice of words, however, those of us who are difficult to treat successfully often refer to ourselves as just that – difficult. Because our condition is… difficult to treat, but not impossible. Patients themselves are not difficult, but as I stated, the condition is resistant to more frequently used options. We may not be intractable however. We may be just… hard. Our attack frequency is too high, and our duration may be long, and pain too much to bear without breaking down. Because our treatment options are extremely limited (in this article anyway) we are far from easy to treat and get satisfactory results. This is not anyone’s fault, it’s just a state of not being easy or typical. Difficult is a word that covers an entire spectrum of possibilities. We are not rebellious, angry or non-compliant, but our situation is… difficult. When used in context, the difficulty is not with the patient, but the disease, and the inability for any of us to find anything that is more than marginally helpful, especially when treatments are so obviously limited. It’s difficult for us, and it’s difficult for doctors who want to help us. It’s terribly frustrating, but personalizing a generalized statement like that isn’t helpful for any patient either. I don’t know of many Migraineurs who wouldn’t refer to their condition as at least difficult.

    As to MOH – there has been quite some discussion through the years among researchers and headache and Migraine specialists re: this term. It is not however, my term. Here at Migraine.com we insist on using the prevailing medical terminology, especially that found in the International Headache Society’s ICHD-II which is what is used by doctors to diagnose and treat Migraine and other headache disorders. We must do this for consistency and for clarity in diagnosis and treatment. Our job is to educate patients, and we can’t do this if we don’t use appropriate terminology, even if we don’t necessarily like the terminology. This is not my term at all, but it’s also not “doctor speak”. We all wish that we could come up with a term that better describes the condition in which frequent use of pain medication has physiologically changed the brain and its pain pathways to cause the very pain we are trying to treat. ICHD-III is due to come out next year, and although I have not yet heard that this particular section is expected to change, physicians and patients together are trying to work on a descriptive term that lessens the perceived burden on patients. It is better than the former terminology, but everyone pretty much agrees that it needs some work. If the term said Medication Abuse Headache, I would agree with your assessment, but it doesn’t. It says overuse, because that is what is happening… pain meds are being used more frequently than the brain can deal with them.

    It’s all in the context… 🙂

    Thanks for your perspective. I think there might be an interesting blog post in this discussion!

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