The Migraine Brain

by Bernstein, Carolyn; McArdle, Elaine

  Caffeine

  Caffeine is the cheapest, easiest, most available drug to treat migraine. It constricts blood vessels, which can decrease pain. Caffeine can be so effective in fighting migraines that many migraine medications include it as an ingredient, including Excedrin Migraine, Advil Migraine, and Motrin Migraine Pain, and prescription drugs like Fiorinal. Caffeine also helps you absorb other medications, which is another reason it is included in some of these migraine medications. And it is a brain stimulant so it can help you think better if you’re in a migraine fog.

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  Caffeine Cure

  If you start to feel a migraine coming on, try drinking a cup or two of strong black coffee or a caffeinated soft drink, a simple treatment that works for many people. Do not drink a sugar-free soda that contains Nutrasweet or any kind of aspartame, which can trigger migraines. Don’t add Nutrasweet to your coffee, either.

  One patient sensed a terrible migraine on its way, grabbed a double-chocolate espresso candy bar at Starbucks (she’s not a coffee drinker), and was able to stave off the migraine. It was a funky treatment—but it was harmless, and it worked for her.

  * * *

  Here’s a fun tool that can help you figure out how much caffeine you are ingesting each day: www.caffeineawareness.org. You can plug in any food or drink, even by brand name, and it will tell you how many grams of caffeine it has. Simply calculating your caffeine number may be helpful in deciding whether you need a caffeine detox. If so, talk to your doctor about how to detox without getting sick.

  Triptans

  “Treating migraines was tricky for me because I’m an alcoholic in recovery. Doctors used to prescribe medication very easily, which was dangerous for me, because I also used to abuse painkillers. So it was like, do I just suffer, or do I take a chance? I’m very glad there’s a pill I can take that’s safe and is not a painkiller.”

  —Trina, 53, who uses a triptan to treat her migraines

  We mentioned triptans at the beginning of this chapter. Most people who try them find significant migraine relief and many are headache free within two hours of taking the drug. And the downside of triptans is minimal for most patients. That’s why triptans should be one of the first drug your doctor considers if you are interested in migraine medication.

  So let’s talk about why triptans work. Triptans address a number of migraine symptoms. They are so called “agonists” for certain serotonin receptors in your brain. By causing blood vessels in the brain to constrict, triptans change blood flow and stop the release of something called substance P, a chemical that causes inflammation and pain.

  There are seven kinds of triptans, and they all work a bit differently. The also have different lengths of time in which they take effect and stay in your body.

  Before triptans came along, doctors didn’t have many good medications to offer migraineurs. The barbiturate-caffeine-analgesic cocktail marketed under the brand names of Fioricet and Fiorinal could help with the pain but did not stop the migraine from occurring, and did not address other symptoms such as nausea. And because the combination included a barbiturate, butalbital, it was potentially addictive—which many patients were never told.

  What a relief that the drug companies finally created medicines designed specifically to abort the migraine.

  Things You Should Know About Triptans

  Triptans will not stop you from getting future migraine attacks, but they can be effective at completely ending a migraine attack in progress.

  You must take a triptan as soon as you feel a migraine coming on in order for it to work. That’s why it’s so important for you to know your migraine warning signs. See Ch. 3.

  Like any drug, triptans have potential side effects. They can be dangerous if you have some kinds of heart disease or high blood pressure. Make sure your doctor knows your complete medical history—especially any heart or blood pressure problems—if you are considering triptans.

  You should not use certain antidepressants called SSRIs if you are using a triptan. This can lead to a potentially fatal overdose of serotonin. Ask your doctor.

  The High Cost of Triptans. Triptans are quite expensive. If you pay out of pocket, a month’s supply could cost you several hundred dollars. Even if you have insurance, your co-pay may be high—$80 a month, say.

  Many insurance plans today are capping how many triptans you can use per month. You can ask your doctor for an override of the cap if it’s indicated. But if you’re using too many abortive drugs, this may be an indication that you need a preventive drug instead of or in addition to an abortive.

  If you don’t have health insurance or your plan won’t pay for triptans, your doctor may be able to help you apply for medicines through an indigent program.

  “Zomig has really helped but right now, my biggest problem with Zomig is fighting with the insurance company to get enough of it. It really is shocking, especially given that I take ten to twelve a month, mainly because my migraines are still very cyclical, with my period.”

  —Roberta, homemaker, 36

  “I was trying to get a refill for my Frova, and, oh, my God, I had to call around, nobody had it in stock. And then they were saying, ‘Your insurance company won’t pay for it unless you have a prior authorization.’ I said, ‘I am pale, I’m dying here! You just need to give me my drugs!’ So I paid $147 for six pills because you just need them. I paid without insurance. I said, ‘I don’t care, I’ll deal with it tomorrow, right now I need my drugs.’”

  —Flannery, 37, veterinary technician

  Take Them When You Need Them. Triptans can cause rebound headaches if you use too many, but what is “too many” varies from patient to patient. Frankly, I see more patients in trouble because of underusing triptans than overusing them. They may hoard them because these meds are expensive and because they’re saving them for a “really bad” migraine.

  Waiting for your headache to get worse can be the worst thing you can do. If you don’t take your triptan early, it won’t work—you can end up really sick, and you’ll need more serious “rescue” medications.

  Other Abortives

  Other abortive medications are available, although they are used less often since the advent of triptans. Perhaps the most commonly prescribed in years past was a class of drugs called ergotomines.

  Ergotamines. Unlike triptans, these drugs can work even if your migraine is in full swing, so you don’t have to take them at the first sign of a migraine.

  DHE-45 is an ergotamine that’s still in use, but I don’t widely recommend it because it has potential side effects such as spasm of blood vessels and ergotism, a condition caused by too much ergot, which can upset your stomach and make you very tired and even confused. There are many contraindications for it, meaning there are lots of drugs with which it does not react well. If you use it, make sure your doctor cross-checks it with all your meds.

  Rescue Drugs

  What do you do if you start to get a migraine, take your triptan or other abortive right away, but the migraine keeps coming—and you are in excruciating pain? This is when rescue drugs are essential.

  Some patients like to have a prescription for a rescue drug on hand in case of emergencies. For example, you may want a prescription for codeine pills or another narcotic in case of an extremely bad migraine. Remember they are highly addictive, so use with caution. These drugs will help with pain and will also help you sleep (and sleep can be one of the best curatives for migraine). I have patients who have prescriptions for these meds but almost never use them. Still, the psychological comfort of having them on hand just in case is tremendous.

  At the Women’s Headache Center, patients with really severe headaches are quickly assessed by my staff. Often, I will give them an injection of ketorolac tromethamine (Toradol), a strong anti-inflammatory that can bring fast relief.

  Most rescue drugs can be addictive, including the “migraine cocktail” once commonly prescribed, and they also can lead to rebound headache
s. So you must be cautious and use them only in cases of severe migraine, when your preventive or abortive meds did not work. Your doctor should prescribe these for you only in small amounts, and she should closely monitor your use of them. In the past, some doctors weren’t careful enough in prescribing these.

  “My gynecologist gave me a prescription for Fiorinal and I took it for a couple of years. I loved the way it felt—dreamy and floating—and I started taking it for every kind of headache, even mild headaches, then menstrual cramps. One day I showed a doctor friend the prescription bottle, and he said, ‘This is serious medicine. How much are you taking?’ I had no idea it was a barbiturate, which I associate with that drug-addicted woman in ‘Valley of the Dolls.’ I was so angry my doctor didn’t tell me that. I found a new doctor, who prescribed Maxalt, which works better anyway.”

  —Fiona, 49, writer

  “They started giving me Fiorinal at age eleven. I only later learned it was a barbiturate and they shouldn’t have been giving it to a kid. It would work a little bit but not much. Although one time I took the Fiorinal along with Drixoral by accident, since I was taking the Drixoral for allergies. That worked—but I was higher than a kite.”

  —Bethany, 32, graduate student

  “I was on Fiorinal for a long time. I ultimately became somewhat addicted to it, and I didn’t realize it until they took me off it because I wasn’t getting any relief and I was walking around in a stupor.”

  —Tom, 44, lawyer

  Note: If you find yourself turning to your rescue meds a lot, talk to your doctor about adjusting your treatment plan. You may need a preventive drug, if you’re not already taking one, or a different kind of abortive med, if yours isn’t working.

  “I’d gotten to the point where I was taking preventive drugs and also pain meds every day. I sat for the bar exam with a note from my doctor saying I needed to have medication with me at the exam. I sat that note and a bottle of pills in front of me. I ended up getting a migraine very early on into the bar exam. I took several Tylenol and codeines, and I ended up failing the bar exam by one multiple choice question. When I failed, I was astounded. But I had taken four codeines! So of course I was not on my game.”

  —Tom, 44, lawyer

  Over-the-Counter Drugs

  For some people, over-the-counter pain medications may be enough to counter the pain of a migraine, if their pain is mild to moderate. Types of over-the-counter (OTC) analgesic (painkiller) include aspirin, acetaminophen, and ibuprofen, all of which come in a variety of brand names. The National Headache Foundation estimates that 15 million people use OTC meds exclusively for treating their migraines.

  While these drugs are comparatively inexpensive and also considered safe, in most cases, the downside is that they may not be giving you pain relief. Nor do they address all migraine symptoms as prescription migraine meds do. If you get frequent, debilitating migraines, OTC medication is probably not the right choice for you, and you should talk to your doctor about whether you should consider a prescription migraine med.

  Standard OTC pain meds include:

  Aspirin—A painkiller that both decreases pain and stops the inflammation response. It is an NSAID (nonsteroidal anti-inflammatory drug).

  Acetaminophen—A painkiller that goes by brand names such as Tylenol. It’s different from aspirin because it’s only a painkiller, not an anti-inflammatory. For that reason, it doesn’t work well for migraine, in most people.

  Ibuprofen—This painkiller is an NSAID that goes by such brand names as Advil and Motrin. It can work in decreasing the severity of pain and decreases inflammation that may be contributing to it.

  OTC Meds Made for Migraines

  There are also over-the-counter drugs made specifically for migraine. Almost all of them are made up of some kind of analgesic of the type we discuss above plus caffeine, which is a very effective migraine drug. For some people with moderate migraines, these OTC migraine meds may work.

  In the past year or so, as migraine has gained increasing prominence as a disease, pharmaceutical companies have begun advertising these OTC migraine meds more heavily on TV and in magazines. They come in a variety of brand names depending on what type of analgesic they include: Excedrin Migraine contains aspirin, acetaminophen, and caffeine; Advil Migraine contains ibuprofen and caffeine; Motrin Migraine Pain contains ibuprofen and caffeine.

  If this is an option you’re interested in, you can buy the brand names or look for generic meds that include these ingredients (a pain reliever plus caffeine) and get the same result. You can also try using a nonmigraine OTC such as ibuprofen and drinking it along with coffee or a caffeinated cola. You may get the exact same result.

  Downsides of OTC Meds. Do not fool yourself into thinking that OTC medications are safer, gentler, or better for you than a prescription drug. Many people tend to overuse OTC pain relievers, which can lead to serious stomach and liver problems. For men, overuse can lead to heart disease. See Ch. 6. Frequent use can also lead to rebound headaches.

  In your headache diary, keep track of how many OTC pain relievers you use in a week and a month. Share this information with your doctor. She can help you see whether you are taking too many and whether a prescription drug is worth considering instead.

  If you are using OTC meds frequently and aren’t feeling much better, a migraine abortive or preventive medication may be right for you.

  Drugs for Other Migraine Symptoms

  Headache pain isn’t the only symptom of migraine, of course. Triptans typically take care of all the symptoms of a migraine because they end the migraine attack, so this may be all you need. But there may be times when you need other medicines to address symptoms besides head pain.

  Nausea and Vomiting. About 80 percent of migraineurs get nausea and one-third vomit, sometimes violently and for a long time. If this is a problem for you and you don’t take triptans or they don’t eliminate your nausea, your doctor may prescribe an antinausea drug. The most commonly prescribed antinausea drugs for migraineurs are prochlorperazine (Compazine) and metoclopramide (Reglan), which have been in use for a long time and are very effective. They may make you sleepy, and, on rare occasions, may result in odd side effects such as involuntary twitching or movement in your arms, legs, or face. Call your doctor if you notice any unusual symptoms like these.

  Prochlorperazine and metoclopramide are safe and cheap, too. If they don’t work for you, ondansetron (Zofran), a chemotherapy antinausea drug, may be the next choice.

  I’ve heard that some doctors prescribe prochlorperazine as a drug that will do more than simply treat the nausea, claiming that it will stop the entire migraine process, including head pain. I haven’t seen this happen with any of my patients.

  Muscle Spasms. Sometimes a muscle spasm can trigger a migraine, perhaps because of inflammation. In these cases, I sometimes recommend the use of cyclobenzaprine (Flexeril), a muscle relaxant, for patients who have muscle strain in addition to the migraines. Typically, I prescribe a low dose, often to be taken at night.

  Diarrhea. Diarrhea can be a migraine symptom for some people but I don’t treat it with medication because there can be a number of causes for it, perhaps unrelated to migraine. You should check with your PCP if diarrhea is an ongoing problem for you.

  Aura. Some people who get aura but no head pain, including people who get ocular migraines, are prescribed triptans to stop the aura. I don’t prescribe triptans for this purpose, however.

  Drug Delivery Systems

  There are many ways to deliver migraine drugs into your body:

  Nasal Spray. This works quickly and is a good choice if you’re vomiting and can’t take a pill. Two triptans come in this form. The problem is, the medicine may taste horrible running down your throat, so if you weren’t nauseated already, you will be after you use the spray! Also, they can irritate your nose. A nasal spray is worth trying if you are looking for fast relief, but you may find that a spray is not for you.

  Injection. In
jection is the fastest delivery system, and it’s often the one doctors use if you end up in an emergency room with a migraine. Your doctor can teach you to inject yourself in the leg with an easy autojet kit. But some people hate needles, and injections are expensive. Also, you need a private place where you can sit down—you can’t whip out a syringe when you’re sitting in an office meeting.

  Tongue Melt. You pop a tab under your tongue and let it melt. It’s convenient because you don’t need a glass of water to get it down, and it works fast. Two triptans—rizatriptan (Maxalt) and zolmitriptan (Zomig)—come in this form

  Suppository. This is an excellent choice if you are vomiting or nauseated. Suppositories aren’t convenient, to say the least, but they work.

  Pills. This is the most common way to deliver medicine but is not a good choice if you are vomiting. And most people need water to take a pill, which isn’t always convenient. Pills are not absorbed into your system as quickly as other methods allow, so if you need super-fast relief, this is not your best choice.