Doctor on Call
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Julia, a 24-year-old aspiring chef who lives in Santa Fe writes:
I’ve had migraine since my early teenage years, and while my headaches can be triggered by skipping meals or too little sleep, they more often occur for no rhyme or reason. I usually can control them with an oral medication. The exception is when I wake up in the morning with a headache that’s already severe. My usual oral medication does absolutely nothing to help, and I simply lie down in a dark quiet room and ride it out. Not a good thing for my job at the restaurant where I work as a pastry chef.
Eventually my doctor prescribed injectable sumatriptan, and its effect the first few times I used it was nothing short of miraculous. My headache, nausea and light sensitivity were completely gone within 15 minutes, and each time I avoided losing a day of my life (and potentially my job).
More recently I have had a few episodes of wake-up-with-it migraine where the injectable sumatriptan worked just fine…but then the headache returned with a vengeance just two or three hours later. Am I having rebound headachea? I use either my oral triptan or the injectable sumatriptan about five or six days every month. Is that too much?
Worried in Santa Fe
The Doctor’s Reply:
Julia,
What you are experiencing is quite common, and it does not result from overuse of the triptans, which is what I presume you, like many, are equating with “rebound” headache.
The toughest migraine headaches are those that have been developing biologically and clinically for a while and have escalated to the point where the pain intensity has reached the level of “severe”. This is often the case when the acute migraine process begins while one is still asleep, and once awake the process is too far along its biologic path for an oral medication to catch up.
The beauty of injectable sumatriptan is that after administration it reaches its peak blood level far more quickly than any orally administered medication, and the concentration of sumatriptan in the blood also is significantly higher than what is achieved with an oral equivalent. Presumably this results in faster delivery of more drug to its intended targets within the migraine circuitry. When migraine headache has progressed to the level of severe intensity, there is “need for speed”, and injectable sumatriptan is a Ferrari compared to the Prius of oral medication.
The downside of injectable sumatriptan is it’s short biologic half-life in the body. Within a matter of a few hours the injected sumatriptan is virtually gone, and unless the roaring fire of the acute migraine was entirely extinguished, it is quite likely to flare up once again. The drug didn’t fail; it just didn’t hang around long enough complete the job. Patients often characterize this early recurrent headache following initially successful treatment with injectable sumatriptan as “rebound” and assume that in some way or another it was the medication that caused this frustrating outcome.
So what can you do to eliminate the early recurrent headache associated with use of injectable sumatriptan? While it’s true that administering the medication without delay, as soon as the headache is moderate to severe intensity, and thereby achieving complete headache relief rather than a reduction in pain lessens the likelihood of early recurrent headache, that strategy is not much help if you are asleep as the migraine is developing.
One obvious option is to anticipate the possibility of early recurrent headache and be ready to administer appropriate oral medication as soon as the recurrent headache begins to develop. Although to do so as “off-label” and lacking a strong evidence base, some physicians advise patients who consistently experience early recurrent headache following use of injectable sumatriptan to administer an oral triptan simultaneous with the injection. The logic is that the oral triptan will be coming on board at about the same time the injectable sumatriptan is exiting the body.
Another option is to treat the initial headache with a medication that has a longer biologic half-life in the body and is associated with a lower likelihood of early headache recurrence. We already have established that oral medications, long half-life or no, typically are too slow in onset to be affective in the setting, but there are alternatives. The half-life of zolmitriptan (Zomig) administered as an intra-nasal spray is somewhat longer than that of injectable sumatriptan; in terms of its rapidity of therapeutic action, zolmitriptan nasal spray is slower than the injectable drug but faster than the oral triptans.
Another interesting option is dihydroergotamine (DHE), and old drug chemically related to the triptans which often is administered intravenously for acute migraine headache that resists self-administered treatment. There is no autoinjector for DHE as there is for sumatriptan, but if your healthcare provider is willing and able to teach you, it can be self-administered subcutaneously/under the skin using a syringe and very small needle. In a head-to-head trial comparing subcutaneously administered DHE with injectable sumatriptan, the DHE was a bit slower to act in relieving headache but, as would be expected from its much longer half-life, was associated with a far lower frequency of early recurrent headache. An intranasal formulation of DHE (Trudhesa) is featured in this issue as a “migraine treatment of the month”, and because the spray containing the medication reaches a portion of the nose richly supplied by blood vessels, the DHE gets to where you want it to go quite rapidly. For some migraineurs who consistently experience early recurrent headache with injectable sumatriptan or who prefer not to self-inject for headache “rescue”, Trudhesa may prove to be an especially attractive alternative.
Hope this helps, Julia, and good luck with the job. We always need more good chefs
