Antimigraine Medications Health Article

Rebound headaches

Rebound headaches are also known as analgesic abuse headaches. They result from overuse of abortive drugs, most commonly the ergot alkaloids. According to one survey of primary care physicians, about 20% of patients treated for migraine experience rebound headaches. These headaches have the following characteristics:

• They occur every day or almost every day.
• They are brought on by a very low level of physical or intellectual activity.
• The patient has been using abortive migraine medications more than two days a week.
• The patient has been using the medications above the recommended dosage level.
• The patient develops withdrawal symptoms if the medications are stopped abruptly.
• The headaches are accompanied by restlessness, depression, irritability, difficulty concentrating, or memory problems.

Status migrainosus

About 40% of all migraine attacks do not respond to treatment with triptans or any other medication. If the headache lasts longer than 72 hours (a condition known as status migrainosus), the patient may be given narcotic medications to bring on sleep and stop the attack. Patients with status migrainosus are often hospitalized because they are likely to be dehydrated from severe nausea and vomiting.

Special populations

CHILDREN Migraines in children are not unusual; a study published in 2003 reported that 10% of children between the ages of six and 20 suffer from migraines, and that they lose, on average, almost two more weeks of school each year than their classmates. Treatment of children's migraines, however, is complicated by the fact that most effective medications—whether abortive or prophylactic—have not been adequately evaluated for use in children or are not recommended for children. As of late 2003, however, there have been few rigorous studies of antimigraine drugs in children; much more research is needed in this area. Cyproheptadine, which is the drug most often prescribed for children's migraines, is not always effective; preventive therapy with propranolol, one of the tricyclics, or an anticonvulsant medication appears to be safe as well as effective in children and adolescents.

PREGNANCY AND LACTATION Pregnancy and lactation complicate migraine treatment in that many antimigraine drugs should not be taken by pregnant or nursing women. These include the ergot alkaloids, anticonvulsants, tricyclic antidepressants, methysergide, and the SSRIs. In addition, NSAIDs should not be used during the last trimester of pregnancy.

OLDER ADULTS Some antimigraine medications are not recommended for patients over the age of 60–65, particularly the triptans and the ergot alkaloids. Older adults may also be more susceptible to the side effects of NSAIDs and TCAs.

Patient dissatisfaction

Antimigraine medications as a group have a high rate of reported patient complaints. One reason is the high cost of some of these drugs; another is dosing difficulties. One survey of migraine patients reported the following reasons for discontent with drug therapy: pain relief took too long (87%); pain was only partly relieved (84%); the medication sometimes failed to work (84%); headache returned within a day (71%); the drug had too many side effects (35%). Because of the limitations of antimigraine medications, many doctors advise their patients to supplement drug therapy with such other measures as adequate sleep and exercise, a low-fat diet, quitting smoking, stress management techniques, or cognitive-behavioral psychotherapy.

It is also worth noting that managed care (the health insurance industry) accounts for some patient dissatisfaction. Most health plans strictly limit coverage to an "average" number of doses of triptans per month. Patients who need more doses either must have their doctors try to get the insurance company to authorize them, or the patients must pay the full price of the extra medication themselves.

It is possible that new ways of thinking about migraine will lead to improved antimigraine medications in the future. Migraine headaches are no longer regarded as "just headaches," but as features of a largely inherited chronic disorder that increases the risk of long-term damage to the brain. The use of MRIs and other new imaging techniques may eventually answer some unresolved questions about effective migraine treatment.

Interactions

Patients who are taking any antimigraine drug should make sure to give the doctor a list of all other medications that they take on a regular basis, including over-the-counter pain relievers, herbal preparations, and any special herbal or medicinal teas or extracts.