Drug update: Moderately severe migraine headaches

OB/GYN News, Sept 1, 2002 by Mitchel L. Zoler, Deeanna Franklin

Triptans have revolutionized the treatment of migraines. More formally known as selective serotonin receptor agonists, triptans are clearly the first class of drugs physicians should consider when treating most patients with migraine headaches that are moderate to severe. Analgesics and nonsteroidal anti-inflammatory drugs are the first-line treatment for patients with mild migraine headaches, and they also are a good first choice for more severe migraines. But by the time most patients seek medical help for moderately severe migraine headaches, they have usually already tried analgesics and NSAIDs on their own, without success.

Ergot derivatives are another option for moderately severe migraine headaches, but in general they're considered inferior to the triptans. Opiates are generally avoided except as a last resort.

The route of delivery can have a major impact on the treatment outcome. Since migraines are often accompanied by nausea and vomiting, oral formulations may not be best. The response rate to the nasal spray form of sumatriptan is similar to that of the oral form. This dosing route is often recommended for adolescents or patients who experience early-morning migraines. The major drawback of nasal sprays is that many patients complain of a bitter aftertaste. An injectable form of sumatriptan is also very effective but is less convenient.

Little clinical data exist to guide the choice of migraine treatment in women who are pregnant or breast-feeding. Avoid triptans and ergot derivatives in these women. For women with severe, persistent, recurring migraines, narcotics and antiemetics may be used to relieve debilitating symptoms. Most pregnant migraineurs have a decrease in the frequency and intensity of their attacks. For breast-feeding women, one possible strategy is to pump breast milk shortly after dosing, then discard it and substitute formula for the next feeding.

In elderly patients, avoid triptans if heart disease is present. For most elderly patients, an analgesic or NSAID is adequate.

Comprehensive guidelines on managing acute migraine headaches were compiled by the American Academy of Neurology and the U.S. Headache Consortium in 2000, and were recently endorsed by the American College of Physicians--American Society of Internal Medicine. The guidelines can be found at http://www.aan.com/public/practiceguidelines/headache_gl.htm.>