Optimal Pharmacologic Treatment of Acute Migraine Headache: Matching medication to headache intensity
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As most migraineurs know well from personal experience, not all migraine episodes are created equal.
For those 20 to 25% of the migraine population who at least occasionally have migrainous aura, an episode of migraine may involve only aura and no headache whatsoever. Or perhaps only aura and prominent postdrome, that final phase of a migraine episode which, for those who have had the experience, closely resembles a hangover.
We often tell our patients that migraine is the “Baskin Robbins of headache”, as the headache of migraine comes in a wide variety of flavors that range from the “classic” severe and pounding half a head headache to much lower intensity and all over the head pain that is identical to the discomfort described by individuals with tension-type headache. And everything in between.
If migraine episodes are so varied in their symptomatology and their clinical course, it only makes sense that most migraineurs will require more than one medication to treat those various types of headache effectively. Injectable sumatriptan may be a magnificent self-administered therapy for “rescue” from your most severe migraine headaches, but it makes little sense to inject sumatriptan for a migraine headache that is in its early stages and involves headache of much milder intensity.
So what is the best strategy? In your arsenal of weapons for acute migraine treatment have a medication which is capable of terminating a migraine episode when the headache is still in the early stages of development and mild in intensity. If you are tolerant of nonsteroidal anti-inflammatory drugs (NSAIDs), then try an adequate dose of, say, naproxen sodium or ibuprofen, and consider washing down your oral medication with a caffeinated beverage. If NSAIDs play havoc with your gastrointestinal track, try an adequate dose of acetaminophen instead. In any event, save the limited supply of your favorite oral triptan, rimigepant (Nurtec), ubrogepant (Ubrelvy) or lasmiditan (Reyvow) for headaches that are more biologically and clinically advanced.
Any of those last mentioned medications is appropriate for “headache on the rise… meaning a headache that has progressed despite your first line therapy (e.g., naproxen sodium and caffeine) or is escalating so rapidly in intensity that it may be best to skip your early/mild migraine headache therapy and go to the next step. If your medication of choice for headache “on the rise” is a triptan, there is wide clinical experience and some limited research data to suggest that combining the triptan with an NSAID (either ibuprofen or naproxen sodium) may be more effective than either medication taking alone. In other words, try a “cocktail” approach: administer a migraine-appropriate dose of the NSAID along with the NSAID and wash them down with your favorite caffeinated beverage. Whether the same “cocktail” approach to using such newer therapies as Nurtec, Ubrelvy or Reyvow is unknown.
If you wake up in the morning and your migraine headache has already reached the stage of being moderate to severe in intensity, orally administrated administered medication may be too slow to catch up with the biologic process generating the migraine and thus incapable of putting your headache “back in the box”. The same holds true for headaches that have advanced from a mild to moderate level of intensity to becoming moderate to severe despite levels 1 or 2 of oral therapy. Now you need speed, and orally administered medication is not going to give you that rapidity of action. Even after all these years, injectable sumatriptan remains the most effective therapy for “rescue” from migraine headache of moderate to severe intensity. If for whatever reason you find injectable sumatriptan to be less than ideal, very nice alternatives for “rescue” include intranasal zolmitriptan and a relatively new link arrival featured in this issue as a “migraine treatment of the month, intranasal DHE (Trudhesa).
In short, from your arsenal of weapons for acute migraine treatment match the medication chosen to the level of headache intensity. Have something on hand for early/mild headache, something for “headache on the rise” and something for “rescue”. Don’t use a BB gun to treat severe migraine headache, and, alternatively, don’t use a guided missile to treat the first inkling of acute migraine headache.
Two commonly asked questions:
If I’m taking a medication for migraine prevention, is it all right for me to continue to use my usual medication for any acute headaches I may have?
Absolutely! If your migraine burden has increased to the point that a course of prevention therapy for stabilization is indicated, rapidly and effectively treating any acute “breakthrough” headaches that occur will play a key supporting role in reducing the hypersensitivity of the nervous system’s biologic circuitry that is generating your headaches. Prolonged episodes of severe migraine headache will work against the prevention medication’s effort to desensitize that circuitry, and snuffing out an acute migraine headache early, soon after it ignites, will assist the prevention medication in the desensitization effort. Rarely is a prevention medication so effective that it entirely eliminates migraine episodes. Expect “breakthrough” headaches, and treat them aggressively.
But I’m having headaches almost every day. If I use medication to treat every one of those headaches, won’t I start having rebound headaches? Treat acute migraine episodes aggressively but don’t overuse acute medication? How can I manage to do both?
An excellent question. Medication overuse headache (commonly referred to as “rebound” headache) occurs when a migraineur uses a given medication or class of medications intended for acute migraine treatment so frequently that the overuse itself begins to generate headache that adds to the existing migraine burden. This often happens subtly, without any dramatic escalation of headache but instead with a gradual overall increase in headache burden (see Doctor on Call in this issue for the important distinction between medication overuse headache (MOH) and “rebound” due to early headache recurrence following a temporarily effective acute treatment response).
Ironically, it is the triptans, the first true “designer drugs” for migraine, that appear to have the highest potential for producing MOH and to do so more rapidly than other medications commonly used for acute migraine. Persistent use of a triptan preparation more than 9 days a month is sufficient to cause MOH and thus to amplify the burden imposed by migraine itself. A sneakier culprit is plain old acetaminophen (in such OTC preparations as Tylenol and Excedrin), easily obtainable and, in the short run, often quite helpful in controlling acute headache. taken more than 15 month days a month persistently, however, just as with the triptans, acetaminophen can produce MOH.
So that’s the bad news. Especially in the first few weeks following initiation of treatment with a prevention therapy, and especially if you are having headache more days than not, it’s difficult not to overuse whatever medication you have been prescribed for acute headache treatment. Two pieces of good news: first, the newer medications for migraine prevention tend to work rapidly for those patients destined to respond, with a positive treatment effect evident as early as the first week, and as the prevention medication desensitizes the migraine circuitry and correspondingly reduces headache burden, the need for acute migraine treatment will progressively decrease; second, even if you are stuck in the swamp of medication overuse headache at the time you begin one of these newer prevention medications, there is compelling evidence that these medications will be just as effective as they would be if MOH was not present. An important caveat to the second point is that not all classes of acute migraine medication are created equal, and there is some evidence to indicate that overuse of opiates/opioids (egs, hydrocodone, oxycodone) or barbiturates (butalbital in particular) may reduce the effectiveness of even the newer prevention medications.
