When treating migraines, we often use the phrase “migraine toolbox”. We want to make sure our patients are well-equipped with the necessary tools to treat their migraines. This toolbox will most likely look different for each patient for various reasons.
Often patients have their own regimen at home and will try typical over-the-counter medications first such as ibuprofen, Excedrin and/or acetaminophen. These medications can be great in moderation if you do not have any pre-existing issues with your liver, kidneys or stomach and will sometimes initially work for a headache. However, over time they may become less effective, which encourages a patient to use more. This makes it even more likely that the medication will cause potential side effects.
At our office, we want our migraine toolbox to have a variety of options to treat each headache, migraine and/or nausea based on that particular attack. A first-line medication will be taken immediately at the onset of a headache or migraine. A second- and/or third-line medication would be taken if the first medication didn’t work at all and/or didn’t provide enough relief from the pain and symptoms of the migraine.
Here’s how we put together a migraine toolbox for one of our patients:
- We’ll recommend over-the-counter or prescription-strength ibuprofen, Excedrin, naproxen or diclofenac potassium for less intense headaches. Limits must be discussed so patients do not end up taking more than what the label recommends, causing stomach ulcers, kidney issues and/or liver issues.
- We will then offer a triptan (which is used to treat acute migraines) as an oral, nasal spray and/or injectable medication. It’s great to have an oral and non-oral option for those quick-onset migraines, especially if nausea occurs. There are over eight different types of oral triptans, some that you swallow and some that dissolve on your tongue. Each of these triptans works differently, so we will switch to a different triptan based on efficacy, side effects and affordability. There are more than four types of nasal sprays and two injectable triptans. Patients often want to utilize an oral pill first because it can be more affordable and easier to carry with them. However, we encourage our patients to have either a nasal spray or injectable as their first line of defense if they wake up with a severe migraine and/or have nausea that might cause them to vomit up the pill. For patients that have had a stroke, cardiovascular event and/or have a cardiovascular risk factor, we can offer them Reyvow as long as those issues are stable. Reyvow is similar to a triptan, but without the vasoconstrictive properties that triptans have, which makes it a safer option for patients with known risk factors who cannot safely use triptans.
- The newer class of acute migraine medications involves blocking calcitonin gene-related peptide (CGRP). CGRP has been shown to dramatically increase during a migraine, which can cause the migraine attack. The two oral options for those are Ubrelvy and Nurtec ODT. These have been excellent additions to our treatment regimen for patients. I highly encourage patients to utilize this class due to there being no cardiovascular risk factors and no migraine rebound potential. Occasionally patients can get a returning headache the next day from certain types of migraine medications if taken too frequently. If a patient fails one of these options, I will still have them try the other. Sometimes patients will take these as a first or second option if the triptans don’t help. We will occasionally have patients take a CGRP acute medication with a triptan or NSAID (nonsteroidal anti-inflammatory drug) for increased efficacy.
- Nausea can accompany a migraine every time or just occasionally. Either way, we want our patients to be prepared. Ondansetron is often our initial choice for patients with nausea during a migraine. It comes in an oral pill or a dissolving option. Most patients tolerate ondansetron well and don’t feel drowsy. If this does not seem to be strong enough, we will often add in promethazine, prochlorperazine, metoclopramide or trimethobenzamide. They come in oral, injectables and rectal suppositories but often have a higher chance of side effects such as sedation.
- We also want our patients to have a backup rescue treatment available to them in an instance when their usual medications don’t work. This might only occur once a month, quarterly or yearly, but our patients must be prepared. We have a variety of options from Trudhesa N.S. (which is a new, gentle and precise nasal spray of dihydroergotamine), butalbital, muscle relaxants, mood stabilizer, low-dose steroids, anti-anxiety and/or anti-seizure medications. We try to avoid prescribing opioids for pain relief now that we have many more treatment options. We have made a lot of accomplishments in the field of migraine treatments over the past four years which has changed how we practice.
Do you have a migraine toolbox approach? If not, please feel to reach out to us at Robbins Headache Clinic and we can get you started.