Julie is 20 years old with severe, prolonged 2 to 3 day migraines twice per month. She also has mild chronic tension headache (CDH). She has difficulty sleeping and is mildly anxious. She occasionally utilizes an inhaler for asthma. As usual, we discuss nonmedication options (psychotherapy, biofeedback exercise, etc.).
With only two migraines per month and mild CDH, a case could be made against prevention medication. However, with the severity and length of Julie's migraines (4 to 6 total days of severe migraine per month), prophylactic medications are indicated. Amitriptyline (Elavil) would be a good choice because of the headaches, insomnia, and anxiety. The asthma limits our selection of medication. We start with amitriptyline, 10 mg per night, increasing after 5 days to 25 mg each night. It is very important with amitriptyline to begin with a tiny dose (10 mg), as many patients cannot tolerate more than 5 or 10 mg. If patients are very tired upon awakening, I instruct them to take the amitriptyline at 7 or 8 pm instead of prior to sleeping. As an abortive, I give Julie sumatriptan (Imitrex) tablets. The abortive medications should not be taken for the mild daily headaches, as we try not to "chase" after daily headaches with pain medications. This avoids the rebound headache situation.
Julie calls 6 days later, and the daily headache is gone but she is very lethargic. We now back off on the amitriptyline from 25 mg back to 10 mg. One month later, the daily headaches are still improved and the Imitrex helps the migraines, but the migraines continue to last 2 to 3 days. At this point, we could add more prevention medication (daily Anaprox, increased amitriptyline, or Depakote), but in general, we want to minimize medication. This, simply treating the migraines with stronger "as needed" medication is the best choice.
For the 2- to 3- day moderate to severe headaches, Imitrex does help, but the headache is returning. We give Julie Decadron 1.5 mg tablets, one every 4 to 6 hours as needed up to six tablets in a month at most. For prolonged severe headaches, cortisone very often is the only effective answer. Naratriptan (Amerge) is a consideration because of the longer half-life than Imitrex. Zomig (zolmitriptan) or Maxalt (rizatriptan) are other onsiderations as well. Amerge is the "kindler, gentler" version of a triptan, with relatively few side effects and a long duration of action. However, it can take up to 2 hours for Amerge to become effective.
Two months later, the daily headaches are back again, and we increase the daily amitriptyline from 10 to 25 mg per night. She is no longer fatigued on this dose. If she became fatigued, we would need to go back to 10 mg of amitriptyline and add protriptyline (Vivactil), 5 mg each morning, or switch completely off amitriptyline to nortriptyline (Pamelor). Protriptyline is not sedating and is effective for daily headaches, but not nearly as effective for migraines as is amitriptyline. Protriptyline never causes weight gain, but has severe anticholinergic effects. Nortriptyline is less sedating than amitriptyline, but much more expensive and not as effective. Imitrex injections would be another consideration, particularly if Julie becomes tolerant to the tablet. The Imitrex injections, while more expensive and inconvenient, are the most effective migraine abortive medication to date. As an alternative abortive, or an adjunct to the triptans, a butalbital medication such as Esgic or Fioricet (these are the same) would be a good choice for Julie because they do not contain aspirin, and she has asthma. However, among the butalbital compounds, Fiorinal, which has aspirin, is the most effective. In general, we try to avoid generic butalbital medications.
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