Migraine Headache (cont.)
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 and thereby reduce inflammation and constrict the blood vessels. This
stops the headache. The triptan with the longest history of use is sumatriptan
(Imitrex). Sumatriptan is
available in the United States as an injection, oral tablet, and nasal spray. 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 2 hours.
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, in patients 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 given to patients who have had heart
attacks and strokes, or to patients 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 have 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. 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 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 patients with high blood pressure,
kidney disease, glaucoma,
atherosclerosis, liver disease, or taking monoamine oxidase inhibitors.
Next: What other medications are used for treating migraine
headaches? »
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