One of the biggest areas of discussion about Migraine and topics of questions is Migraine Medications. Discussing Migraine medications can get confusing, partly because there are so many, partly because they're used for different purposes. Migraine medications fall into three categories -- preventive medications, abortive medications, and rescue medications.

Preventive Medications
Preventive medications are taken daily to reduce the frequency and severity of Migraine attacks. Most doctors recommend preventive medications if you average one Migraine a week or more. Some people are naturally reluctant to start taking a daily medication that may need to be taken indefinitely. Here's where we need to stop and think a bit. Migraine is a genetic neurological disease, not just having bad headaches. Most people aren't so reluctant to take daily medications for diseases such as diabetes or thyroid disease. Once we get our heads around the fact that Migraine is a disease, resistance to taking daily medications seems to lessen.

There are only four medications that have been officially approved by the FDA for Migraine prevention:

• Inderal (propranolol), a beta blocker originally developed for heart disease and high blood pressure
• Blocadren (timolol), another beta blocker
• Depakote and Depakote ER (divalproex sodium), a neuronal stabilizing agent, also known as an anticonvulsant, originally developed for seizure disorders
• Topamax (topiramate), another neuronal stabilizing agent

There are many other medications (more than 100 total) that are being used effectively for Migraine prevention. It's quite common for medications to be prescribed for conditions other than those for which they were first developed. This is called off-label prescribing. Medications prescribed off-label for Migraine prevention include:

• Antihypertensives (blood pressure medications)
  • Alpha-2 Agonists such as Clonidine
  • ACE Inhibitors such as Monopril
  • Beta Blockers such as Lopressor and Corgard
  • Calcium Channel blockers such verapamil, Cardizem, and Plendil
• Antihistamines such as Periactin
• Antidepressants
  • Tricyclic antidepressants such as amitriptyline
  • SSRI antidepressants such as Paxil and Lexapro
  • SNRI antidepressants such as Effexor
  • MAOI antidepressants such as Nardil
• Cox-2 Enzyme Inhibitors such as Celebrex
• Muscle relaxants such as Soma and Zanaflex
• Neuronal stabilizing agents (anticonvulsants) such as Keppra, Topamax and Zonegran
• Leukotriene Blockers such as Singulair and Accolate
• Medications generally used for ADD such as Adderall and Strattera
• Medications developed for dementia or Alzheimer's disease such as Namenda
• Botox
• Dietary supplements such as Coenzyme Q10, vitamin B2, Petadolex, and magnesium
   

Abortive Medications
Abortive medications actually work in the brain to stop the Migrainous process. They work to reverse the dilation of blood vessels and inflammation of the surrounding nerves and tissue. When effective, abortives stop the Migraine attack and the associated symptoms. Migraineurs may still experience the Migraine postdrome, that phase that some people call a "Migraine hang-over." Migraine abortives include:

• Triptans: Imitrex, Maxalt, Zomig, Amerge, Axert, Relpax, and Frova
• Triptan and NSAID compound: Treximet
• Ergotamines such as Migranal nasal spray and DHE-45 (injectable)
• Isometheptene compounds such as Midrin (now discontinued), Epidrin, and Prodrin.

In a few cases, triptans are used for Migraine prevention. Amerge and Frova have been studied and proven effective for the prevention of menstrually triggered Migraines when taken twice a day for five to seven days beginning two days before the onset of the menstrual period.

On April 15, 2008, a new variation on a triptan was introduced, Treximet. Treximet combines sumatriptan (Imitrex) and naproxen sodium, an NSAID. The purpose for this combination is for the sumatriptan to target the nerves and blood vessels involved in a Migraine while the naproxen sodium targets inflammation.
 

Rescue Medications
Rescue medications are those taken if abortives fail or if you can't take the abortive medications. Most rescue medications are pain medications. Other types of medications are also used to help get through a Migraine by reducing nausea and helping Migraineurs relax. They don't have the ability to abort a Migraine, but will hopefully mask the pain for a few hours while the Migraine runs its course. Medications used for rescue include:

• Butalbital compounds: Fiorinal, Fioricet, etc. (with or without codeine)
• Acetaminophen with codeine, oxycodone, or hydrocodone such as Vicodin, Percocet, Tylenol #3
• Other analgesics (pain relievers) such as Ultram, Toradol, Nubain, and others
• In some cases, doctors will prescribe injectable medications such as Demerol to be used at home in emergencies.
• Antinausea medications such as Compazine, Phenergan, Reglan, and Zofrean
• Muscle relaxants such as Soma, Skelaxin, and Zanaflex
   

Summary
Which medications are part of your regimen depends on you and your Migraines. Migraineurs with infrequent mild to moderate Migraine may do fine with abortive medications only. There are also some in that situation who can even manage with a mild pain reliever. For those whose Migraines are frequent, the most effective regimen will include preventives to reduce the frequency and severity of Migraines, abortives to stop Migraines as they occur, and rescue medications to help avoid trips to the emergency room if abortives fail. Some Migraineurs, particularly those with a history of cardiovascular disease, may have been told not to use abortives other than Midrin and its equivalents and will need to limit their regimens to preventive and rescue medications if Midrin is not effective for them. Additionally, there are some Migraine specialists who opine that Midrin is no safer in regard to cardiovascular issues than the triptans because the isometheptene mucate in it is a vasoconstrictor.

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Resources:

Goadsby, Peter J., MD, PhD, DSc, FRACP, FRCP; Silberstein, Stephen D., MD, FACP; Dodick, David W., MD, FRCPD, FACP. "Chronic Daily Headache for Clinicians." Hamilton, Ontario: BC Decker. 2005.

Evans, Randolph W., MD; Mathew, Ninan T., MD, FRCP(C). "Handbook of Headache." Lippincott Williams & Wilkins, 2005, second edition.

Klapper, J., Mathew, N. & Nett, R. (2001) "Triptans in the Treatment of Basilar Migraine and Migraine With Prolonged Aura." Headache: The Journal of Head and Face Pain 41 (10), 981-984. doi: 10.1046/j.1526-4610.2001.01192.x

Young, William B. and Silberstein, Stephen D. Migraine and Other Headaches. St. Paul, Minnesota: AAN Press, 2004.

  
Medical review by John Claude Krusz, PhD, MD

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