A Pharmacy Guide to Medications
There are many articles written about remedies and life experiences that can assist in the prevention and treatment of migraine attacks. Many contain valuable information about food, lack of sleep, hormonal changes, family history etc but Pharmacy is an evidence based science around the studies which prove the effective action of the medicines sold or prescribed.
Pharmacists also know that every person can be different and quite often migraine attacks differ in characteristics, so it can be helpful to share a few basics about the symptom relief options in order to assist each Migraine Sufferer make the most of the medicines available.
Patients who are actively involved in the management of their migraines need to have an understanding of the treatments available today.
During an acute attack all oral medication is compromised by stomach shutdown. It means that the medication just doesn’t get into the bloodstream, doesn’t get to the site of the pain and it can take experimentation over a few attacks to establish which drug, dosage and form (suppository, tablet or injection) is most effective at each stage of the migraine attack.
With early trigger recognition some mild attacks respond to simple analgesics while more severe attacks require specific migraine treatments.
What types of treatments are there?
NSAIDS
Paracetamol (e.g. Panadol® and Pamol® is a first choice of pain relief for both acute and chronic pain. Chronic abuse of Paracetamol may cause severe liver damage and accurate dosing is very important.
Dosage recommendations: 15mg/km body weight for children; 1gm-1.5gm every 4-6 hours up to a maximum of 4 doses in any 24 hours
Aspirin and Ibuprofen (e.g. Nurofen®) belong to the group of medicines known as Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Aspirin is the oldest medicine in use today and Ibuprofen has been available since 1985, they have similar side effects – people with aspirin sensitivity, asthma and stomach disorders should not be taking Ibuprofen without doctor’s advice. Nurofen Migraine Pain ® is the new Lysine formulation which is proven to be absorbed even with stomach shutdown and it does not have to be taken with food.
Dosage Recommendations: Adults and children over 12 years 200 – 400mg every 4-6 hours up to a maximum of 6 tablets/24 hours.
Codeine Phosphate
Codeine phosphate is available in combination with Paracetamol (e.g. Panadeine®).
Codeine acts centrally in the brain to take away the awareness of moderate pain. Side effects include constipation and drowsiness in older people.
Dosage Recommendations: Adults 8-10mg up to 4 hourly
ANTI-EMETICS
Metoclopramide can be taken to prevent nausea and vomiting, and in combination with Paracetamol (e.g. Paramax®) to enhance the absorption of the pain relief.
ACUTE TREATMENTS
Ergotamine is a non selective vasoconstrictor which is most effective when taken as early as possible in a migraine attack, usually 2mg by mouth repeated if necessary half an hour later to a recommended maximum of 6mg per day or 12mg per week. It is not suitable for people with hypertension or cardiovascular disease. It can be taken with caffeine to assist in the absorption of the drug. There can be a rebound effect in some patents and long term use is not recommended.
TRIPTANS
E.g. Arrow Sumatriptan, Sumatriptan (Imigran®), Rizatriptan (Maxalt®) – these are selective vasoconstrictors of the cranial blood vessels. They have less severe adverse effects than ergotamine compounds and are active at all stages of the migraine attack. Oral doses of 50mg or 100mg take about 30 minutes to relieve symptoms, if they reoccur after 2 hours a second dose can be taken up to 2 in 24 hours. Injected 6mg and if symptoms recur a second dose provided there is 1 hour between and a maximum of 12mg in 24 hours.
Patients taking ergotamine should wait at least 24 hours before taking any Triptans and there should be at least a 2 week wash out time if a patient is taking other medications e.g. MAOIs (e.g. Moclobemide) or SSRIs (e.g. Prozac®) or St John’s Wort.
(MAOI –a class of drugs called Mono-Amine Oxidase Inhibitors. SSRI- Seratonin Re-uptake Inhibitors)
PREVENTATIVE THERAPIES
Pizotifen (Sandomigran®) claimed to have helped about 50% of patients to prevent migraines, they are not effective in treating an attack, and they can cause sleepiness and may increase the appetite. Adult doses start on 0.5mg daily and can increase to 1.5mg for maintenance.
Cyproheptadine (Periactin®) is used to both prevent and treat migraines at a dosage starting at 4mg which can be repeated after 30 minutes -8mg maximum every six hours.
Propranolol and Nadolol are Beta blockers that can help patients with severe migraines but are not suitable for those who suffer from asthma. Propranolol dosage is initially 40mg 2 or 3 times a day increasing to a maximum of 160mg daily. Children over 12 years can be given 20mg 2 or 3 times a day.
TRICYCLIC ANTIDEPRESSANTS
Amitriptyline is one antidepressant widely prescribed for patients who are depressed as well as non-depressed individuals to relieve their migraines. Patients are often required to take maximum doses for periods of 6 months to avoid relapses.
COMPLIMENTARY TREATMENTS
Migradol® is a nutrient formulation containing Vitamin B2 and Magnesium the recommended treatment is 2 capsules taken twice a day at meal times for 30 to 60 days
Feverfew (Tanacetum parthenium) is a herb which can be eaten fresh in salads or taken in a capsule, one daily with breakfast may assist in preventing the symptoms of migraine headaches if taken over a prolonged period of time.
The above list is only an overview of treatments available, there are more medicines available overseas and many more still in their developmental stages. It is important to emphasise that at present migraines are not totally curable and no medication will totally eliminate all symptoms but as research and development continues your pharmacist is a knowledge source available to help each migraine sufferer maximize the effective use of their medication.
Lorraine Balfour Auckland Community Pharmacist.
(Ref. NZ Pharmacy October 2003)
