A Comprehensive Medicine approach to migraines

Townsend Letter for Doctors and Patients, Jan, 2005 by Jacob Teitelbaum

For this pain issue, I have excerpted part of the section on the treatment of migraines from my new book Pain Free 1-2-3!-A Proven Program to Get You Pain Free (the book and info on our Hawaii February 4-6, 2005 pain management conference are available at www.vitality101.com). The book teaches a Comprehensive Medicine approach to overall pain management for both prescribing and non-prescribing practitioners.

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Migraines

These headaches can be very severe and often leave people crippled for days. They may afflict as many as 28 million Americans. Migraines are often preceded by an "aura," which may consist of visual disturbances such as flashing lights. The headaches are often associated with nausea, sweats, dizziness, and slurred speech. Light and sound sensitivity can also be severe.

There is still marked debate over the cause of migraines. For decades, researchers thought that these occurred because of excessive contraction and expansion of the blood vessels in the brain. Others thought that this blood vessel problem occurred because of inadequate serotonin, the neurotransmitter that controls sleep and mood, which also plays a role in how blood vessels expand. Low serotonin also amplifies pain by increasing the pain neurotransmitter called substance P. Muscle spasm and nutritional imbalances and deficiencies can also contribute to migraines, as can food sensitivities. Most likely, it is a common endpoint for many different underlying problems.

Effective migraine treatment is important. Not only are migraines horribly painful, but they are expensive as well. The average amount of work missed by those with migraines is 19.6 days a year, costing employers $3000 per year per employee. It is also under-treated, with 31% of migraine patients never having sought treatment. (6)

What Medications Can I Take to Get Rid of an Acute Migraine Headache?

In the US, medications in the Imitrex[R] family still remain the first choice. This new family of medications, called triptans, has increased our ability to dramatically treat migraine headaches effectively. Imitrex comes in 25,50, and 100 mg tablets, and up to 100 mg may be taken at a time. If pain persists at 2 hours, another dose of up to 100 mg can be taken. In addition, it is also available by nasal spray, using a dose of up to 20 mg initially, followed by one more spray of up to 20 mg 2 hours later if needed. Another alternative is a 6 mg subcutaneous injection, which can also be repeated 1 hour later if needed. It is reasonable to try these different forms to see what works best for your migraines. You may also want to try a newer cousin called Amerge[R]. Use 2.5 mg initially. This dose may be repeated 4 hours later if needed. Your physician may also use other related medications such as Zomig[R], Axert[R], or Relpax[R].

Imitrex has been found to be effective in eliminating an acute migraine attack in 34 to 70% of patients within 2 hours. Unfortunately, at least 30 to 40% of patients remained unsuccessfully treated. (7) Axert[R] (almotriptan 6.5 to 12.5 mg, which can be repeated in 2 hours) is similar in effectiveness to Imitrex but less expensive ($10.50 vs. $16.50).

Other treatments may be effective for acute migraine when Imitrex is not. Aspirin family medications do not work well in migraines because the absorption of aspirin is delayed during the migraine attack. To combat this problem, medications that enhance absorption can be added to the aspirin and/or it can be given by suppository. For example, a combination of indomethacin (a "super-aspirin"), prochlorperazine (for nausea and to enhance absorption), and caffeine in suppository form were compared with Sumatriptan[R] rectal suppositories for acute migraines. Forty-nine percent of patients were pain free at 2 hours on the first treatment as compared to 34% with the Sumatriptan. (8) Another study using a similar approach had the same result. Aspirin (lysine acetyl salicylates 1620 mg -- equivalent to 900 mg of aspirin) was combined with Metoclopramide[R], 10 mg. The latter medication returns the absorption of aspirin to normal during migraine attacks and also combats nausea and vomiting. In the two placebo-controlled studies, this combination was more effective than 100 mg of Imitrex by mouth and was better tolerated. (9-11) These combinations can be made by compounding pharmacists. It is quite likely that regular aspirin, especially if chewed, would be as effective as the form used in the study. Metoclopramide is readily available.

Other medications can also be helpful for acute migraines. Many patients get relief with Midrin[R], which is a mix of three medications. Take 2 capsules immediately followed by 1 capsule every hour until the headache is relieved (to a maximum of 5 capsules within a 12 hour period). It can also be helpful for tension headaches in a dose of 2 capsules 4 times a day, as needed. Many patients find this to be quite helpful and it is not addictive. Fiorinal[R] can also be effective but is addictive, and I prefer not to use this medication.