Short-Term Option for Migraine Prevention: Frova
For many women with migraine, their menstrual migraines are the most disabling. Research shows that menstrual migraine headaches last longer and are associated with a greater level of disability than non-menstrual migraines. In addition, they are often more refractory to treatment. Many women in my headache practice report that their acute treatment, most often an oral triptan like Sumatriptan (Imitrex) works well for most of their migraines but not their menstrual migraines. Or, in other cases, the triptan works but the menstrual migraine comes back and can last for 5-7 days.
Menstrual migraine is predictable for many women if they are having regular menstrual cycles. Therefore, treatment can be targeted for short-term prevention of this disabling, prolonged monthly headache. Ideally, treatment is started for several days before the anticipated menstrual migraine and continued until the end of menses or until the end of the vulnerable period which in some cases may extend for several days after cessation of menses.
Many of the seven triptans have been shown in clinical studies to help prevent menstrual migraine, including Sumatriptan (Imitrex), Naratriptan (Amerge), Zolmitriptan (Zomig), and Frovatriptan (Frova). Frova was studied in a large, placebo-controlled trial and found to prevent menstrual migraine for 3 cycles in over 50% of the women in the study.  Significantly, women did not experience rebound headache after the Frova was stopped. For these reasons and because Frova has the longest duration of action of all the triptans (26 hour duration), it is particularly well-suited for short-term prevention of menstrual migraine. The dosing in the study was as follows:
- Day 1: Take a loading dose of Frova 5 mg (take 2 of the 2.5 mg tablets)
- Day 2-6: Take Frova 2.5 mg twice a day for 5 days
- Total number of tablets needed: 12
The question is: could Frova also be an option for short-term prevention of other predictable migraines such as migraines triggered by high altitude or travel?
Answer: Yes and I have had many patients do this quite successfully. For example, if a patient is going on a trip to a high altitude and typically experiences migraine at higher altitudes, Frova can be taken the day prior to going up to the high altitude and stay on the Frova either once or twice a day as short-term prevention during their trip.
The dosing schedule used in this published clinical trial can be adjusted depending on how many days short-term prevention is needed and depending on how many Frovatriptan tablets are covered by the patient’s insurance company. Most insurance companies have a limit of 9 triptan tablets a month. Starting with one Frova tablet on the first day of menstrual migraine and then taking 1 a day for 3-5 days may be an effective alternative to the higher twice a day dosing used in the clinical trial. However, in some cases, the twice a day dosing may be needed for optimal prevention.
A patient of mine with frequent migraines was nervous she was going to get a migraine on her wedding day. I had her start Frova 2.5 mg once a day for several days prior to her wedding and continue to take daily Frova until back from her honeymoon. Our strategy worked well and she was headache-free the whole time!
Another way I use Frova short-term is to prevent a severe migraine from returning. For example, if a patient of mine has had to go to an ER or Urgent Care and receive injectable or intravenous medication for migraine rescue, it can be useful to prescribe Frova for 3-5 days to prevent the migraine from returning. Frova tends to be non-sedating and very well-tolerated.
Other medications can also be dosed for short-term prevention such as an anti-inflammatory (Naproxen, Ibuprofen) and magnesium. Both have shown benefit over placebo in the treatment of menstrual migraine. Also, short-term treatment with “add-back” estrogen during menses can be a useful short-term strategy for menstrual migraine. For many women, several strategies are combined for greater potential success.
In summary, short-term prevention of menstrual migraine with Frova can be successful in preventing menstrual migraine in over 50% of women according to clinical trials. This same strategy can be used to prevent other migraine exacerbations if triggers can be identified and predicted such as high altitude, travel, or times of high stress. 1
Can you tell when a migraine attack is coming?