Triptan
Formulations
Dosages (mg)
Sumatriptan
Oral
25, 50, 100, 85 with 500 mg naproxen
Nasal spray
5, 20
Subcutaneous injection
4, 6
Transdermal
6.5
Rizatriptan
Oral
5, 10
Oral melting tablet
5, 10
Zolmitriptan
Oral
2.5, 5
Oral melting tablet
2.5, 5
Nasal spray
2.5, 5
Naratriptan
Oral
1, 2.5
Eletriptan
Oral
20, 40
Almotriptan
Oral
6.25, 12.5
Frovatriptan
Oral
2.5
Dihydroergotamine remains a widely used ergot in the management of acute migraine pain. It is less receptor specific than the triptans and, therefore, is more prone to side effects such as nausea, but some patients find it to be more efficacious than triptans. It is available in a nasal spray formulation as well as an injectable that can be given subcutaneously, intramuscularly, or intravenously.
For patients with intractable migraine headache who are in an inpatient setting, dihydroergotamine can be given repeatedly over a number of days.
1.5.2 Preventive Medication
When patients suffer with frequent migraine headaches, they may become candidates for the use of preventive medication options. Although there is no absolute number of headache days per month threshold, a general cutoff has traditionally been at two headache days per week. This has come under scrutiny recently as there are other variables that factor into the decision, including severity of the headache, associated symptoms, success of acute treatments, and patient preference. Some patients may desire daily preventive medication over even the occasional severe, disabling headache, while others may prefer to treat acutely rather than take daily medicine. Of note, the presence of nine or more headache days per month has been shown to be an independent risk factor for the progression to chronic migraine, so serious consideration for prevention may be warranted in patients with what is commonly referred to as high-frequency episodic migraine.
There are several general principles for the selection and use of preventive medications. Start the medication at a low dose, and then progressively increase the dose over time until headaches are sufficiently limited or side effects are no longer tolerable. Preventives should be maintained for at least 2–3 months before a determination of efficacy is made. Selection of which agent to use can be aided by looking for the “therapeutic two for one,” or choosing a medication that can treat both the migraines and another issue for the patient (depression, insomnia, hypertension).
The US Food and Drug Administration has only approved four agents for the prevention of migraine: topiramate, valproic acid, propranolol, and timolol. A number of other medications are commonly used, including other antiepileptics and antihypertensives and antidepressants. Recently the American Academy of Neurology and the American Headache Society published a review of the evidence for preventive medications, which are summarized in Table 1.2.
Preventive medication | Common dosages (mg) | Level of evidence |
|---|---|---|
Divalproex sodium/sodium valproatea | 250–1,500 | A |
Topiramatea | 50–200 | A |
Metoprolol | 50–150 | A |
Propranolola | 80–240 | A |
Timolola | 20–60 | A |
Amitriptyline | 10–150 | B |
Venlafaxine | 75–225 | B |
Atenolol | 50–200 | B |
Nadolol | 20–160 | B |
Lisinopril | 10–20 | C |
Candesartan | 16 | C |
1.5.2.1 Antiepileptic Drugs (AEDs)
Topiramate
Topiramate was initially approved by the US FDA for the treatment of certain epilepsies but has since gained approval for the prevention of migraine. Common doses are between 100 and 200 mg per day, either once or twice daily. It is recommended to start at a lower dose, often 15 or 25 mg, and slowly titrate the dose to avoid side effects. The most commonly reported side effects are paresthesias, or a pins and needles sensation in the hands, feet, or perioral region, cognitive changes, and appetite suppression or taste changes. Carbonated beverages are often perceived as being flat or having a metallic taste. Topiramate can increase the risk of renal calculus formation and should be used with caution or avoided in those with a history of stones. It has been reported to induce acute angle closure glaucoma, and reports of severe eye pain should lead to discontinuation of therapy and urgent ophthalmologic evaluation. Like many of the preventives used, it shows roughly a 50 % reduction of headache frequency in 50 % of those treated.
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