Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
What is the treatment for moderate to severe migraine
headaches?
Migraine-specific abortive
medications usually are necessary for moderate to severe migraine headaches. The
abortive medications for moderate or severe migraine headaches are different
than OTC analgesics. Instead of relieving pain, they abort headaches by
counteracting the cause of the headache, dilation of the temporal arteries. In
fact, they cause narrowing of the arteries. Examples of migraine-specific
abortive medications are the triptans and ergot preparations.
Triptans
The triptans attach to serotonin receptors on the blood vessels and nerves that surround them, constrict the blood vessels, and reduce the inflammation. This
stops the headache. The triptan with the longest history of use is sumatriptan
(Imitrex). Sumatriptan is
available in the US as an injection, oral tablet, and nasal inhaler. Zolmitriptan (Zomig) and
rizatriptan (Maxalt) are newer triptans that are available as oral tablets and
as tablets that melt in the mouth. Naratriptan (Amerge), almotriptan (Axert) and
frovatriptan (Frovalan) are available only as oral tablets.
Traditionally, triptans were prescribed for moderate or severe migraines
after OTC analgesics and other simple measures failed. Newer studies suggest
that triptans can be used as the first treatment for patients with migraines
that are causing disability. (Significant disability is defined as more than 10
days of at least 50% disability during a three-month period.). Triptans should
be used early after the migraine begins, before the onset of pain or when the
pain is mild. Using a triptan early in an attack increases its effectiveness,
reduces side effects, and decreases the chance of recurrence of another headache
during the following 24 hours. Used early, triptans can be expected to abort
more than 80% of migraine headaches within two hours.
The U.S. Food and Drug Administration (FDA) has issued a warning about taking triptans together with medications of the SSRI (selective serotonin reuptake inhibitor) or SNRI (selective serotonin/norepinephrine reuptake inhibitor) classes. Taking these medicines together can cause a serious condition called serotonin syndrome.
Side effects of triptans
The most common side effects of
triptans are facial flushing, tingling of the skin, and a sense of tightness
around the chest and throat. Other less common side effects include drowsiness,
fatigue, and dizziness. These side effects are short-lived and are not
considered serious.
The most serious side effects of triptans are
heart attacks and
strokes.
Triptans are effective in migraine headaches because they narrow arteries in the
head; however, they also can narrow arteries in the heart. In individuals
without existing carotid or coronary artery disease, the narrowing caused by
triptans usually does not cause problems. However, persons whose carotid and
coronary arteries are narrowed by atherosclerosis or who suffer from
intermittent spasm of the coronary arteries (a condition called Prinzmetal's or
variant angina), the narrowing caused by triptans can further reduce the flow of
blood through the arteries and have been reported to cause heart attacks and
strokes. Therefore, triptans should not be used by those who have had heart
attacks and strokes, or those who have symptoms of atherosclerosis such as
angina,
transient ischemic attack (TIAs), and intermittent claudication.
Healthy adults may have atherosclerosis and narrowing of the coronary
arteries that are "silent", that is, without past strokes, transient ischemic
attacks, heart attacks, or angina. Therefore, before prescribing a triptan, a
doctor should evaluate patients for possible atherosclerosis if they have one or
more risk factors for developing atherosclerosis. These risk factors include
cigarette smoking, diabetes
mellitus, high blood pressure, high levels of LDL ("bad")
cholesterol in the blood, obesity, male and over 40 years
of age, female and postmenopausal, or a family member(s) who has had heart
attacks at an early age. Some patients who are at risk should receive their
first dose of a triptan in the doctor's office while being monitored with an electrocardiogram (EKG).
Triptans can interact with other drugs. For example, there have been rare
reports of triptans causing a "serotonin syndrome" when given together with a
selective serotonin reuptake inhibitor. Selective serotonin reuptake inhibitors
(SSRIs) are a class of medications widely used to treat depression. The symptoms
of serotonin syndrome include confusion, fever, tremor, high blood pressure,
diarrhea, and sweating. Certain triptans such as sumatriptan, zolmitriptan, and rizatriptan
can interact with monoamine oxidase inhibitors. Propranolol (Inderal) can raise
rizatriptan blood levels. Cimetidine (Tagamet) can increase
zolmitriptan blood levels.
Triptans should not be used in
pregnant women and are not generally used in
young children.
Ergots
Ergots, like triptans, are medications that abort migraine
headaches. These may be combined with caffeine and/or other pain relief
medications in combination products. Examples of ergots include ergotamine preparations (Ergomar,
Wigraine, and Cafergot) and dihydroergotamine preparations (Migranal, DHE-45).
Ergots, like triptans, cause constriction of blood vessels, but ergots tend to
cause more constriction of vessels in the heart and other parts of the body than
the triptans, and their effects on the heart are more prolonged than those of the
triptans. Therefore, they are not as safe as the triptans. The ergots also are
more prone to cause nausea and vomiting than the triptans. The ergots can cause
prolonged contraction of the uterus and
miscarriages in pregnant women.
Midrin
Midrin is used to abort migraine and
tension headaches. It is a
combination of isometheptene (a blood vessel constrictor), acetaminophen (a pain
reliever), and dichloralphenazone (a mild sedative). It is most effective if
used early during a headache; however, because of its potent blood vessel
constricting effect, it should not be used in persons with high blood pressure,
kidney disease, glaucoma,
atherosclerosis, liver disease, or taking monoamine oxidase inhibitors.
Headaches can be divided into two categories: primary headaches and secondary headaches. Migraine headaches, tension headaches, and cluster headaches are considered primary headaches. Secondary headaches are caused by disease. Headache symptoms vary with the headache type. Over-the-counter pain relievers provide short-term relief for most headaches.
A stroke results from impaired oxygen delivery to brain cells via the bloodstream. A stroke is also referred to as a CVA, or cerebrovascular incident. Symptoms of stroke include: sudden numbness or weakness of the face, arm or leg. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes, sudden trouble walking, dizziness, or loss of balance, and/or sudden severe headache with no known cause. A TIA, or transient ischemic attack is a short-lived temporary impairment of the brain caused by loss of blood supply. Stroke is a medical emergency.
Fibromyalgia, formerly
known as fibrositis, causes chronic pain, stiffness, and
tenderness of muscles, tendons, and joints without detectable inflammation. Fibromyalgia patients have an unusually low pain threshold. Symptoms of fibromyalgia include fatigue, abnormal sleep, mental/emotional disturbances, abdominal pain, migraine and tension headaches, and irritable bladder. Treatment of fibromyalgia involves patient education, medication, exercise, and stress reduction.
A tension headache is a headache previously thought to be caused by contraction of the muscles in the back of the neck, on the scalp, and sometimes in the jaw. The term tension-type headache is now preferred, reflecting the fact that research has shown that these headaches may not be related to muscle tension.
Sinus headache is caused by a sinus infection or inflammation of the sinus cavities. The primary symptom of a sinus infection is pain and increasing pressure overlying the area and associated tenderness to the touch. Treatment of a sinus headache depends on the cause.
Mercury is a naturally occurring element found in water, soil, and the air. Mercury is also contained in some fish, some of the products we use in the home, school, or dentist. Information about sources of mercury exposure, potential health effects, symptoms of exposure, fish that may contain mercury, consumer products that contain mercury, and ways to reduce your exposure to mercury is important for the health of you, and your family.
Pain management and treatment can be simple or complex, according to its cause. There are two basic types of pain, nociceptive pain and neuropathic pain. Some causes of neuropathic pain includes: complex regional pain syndrome, interstitial cystitis, and irritable bowel syndrome. There are a variety of methods to treat chronic pain, which are dependant on the type of pain experienced.
Chronic pain is pain (an unpleasant sense of discomfort) that persists or progresses over a long period of time. In contrast to acute pain that arises suddenly in response to a specific injury and is usually treatable, chronic pain persists over time and is often resistant to medical treatments.
The term cluster headache is a type of headache that recurs over a period of time. There are episodes that last one to three times a day during a period of time, which may last from 2 weeks to 3 months. There are three main types of treatment abortive medications, preventive medications, or surgery which involves blocking the trigeminal nerve.
Double vision (diplopia) is a symptom that my indicate Graves' disease, myasthenia gravis, stroke, multiple sclerosis, Guillain-Barre syndrome, diabetes, cataracts, aneurysm, brain tumor, or migraine. Symptoms and signs include eye pain, droopy eyelids, nausea, headache, and a cross-eyed appearance. Treatment of double vision depends upon the underlying cause.
Kids get headaches and migraines too. Many adults with headaches started having them as kids, in fact, 20% of adult headache sufferers say their headaches started before age 10, and 50% report their headaches started before age 20.
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