Headaches: Relieving and preventing migraine and other headaches

• Introduction
• Headache basics
  • What type of headache do you have?
• Evaluating your headache
  • When to see your doctor
  • The office visit
  • Diagnostic tests
• First steps in treatment
  • Over-the-counter medications
  • Working with your doctor
• Tension headache
  • Triggers and aggravators
  • Relieving tension headache
  • Preventing tension headache
• Migraine headache
  • Anatomy of an attack
  • Timing of attacks
  • Who’s at risk?
  • Migraine triggers
  • Preventing migraine headache
• SPECIAL BONUS SECTION: Mitigating migraine pain
• Chronic daily headache
  • Drug-rebound headache
  • Relieving chronic daily headache
  • Preventing chronic daily headache
  • Further options
• Cluster headache
  • Relieving cluster headache
  • Preventing cluster headache
• Sinus headache
  • How sinus headache develops
  • Relieving sinus headache
  • Preventing sinus headache
• Self-help and alternative techniques to ease headaches
  • Avoiding triggers
  • Physical therapy
  • Mind-body techniques
  • Exercise
  • Acupuncture
  • Psychotherapy
  • Herbal remedies and dietary supplements
• Headache diary
• Glossary
• Resources

Throughout history, migraine sufferers have endured an odd array of alleged remedies. Ancient Romans zapped headache pain with a jolt from a black torpedo fish, or electric ray. In the 13th century, Europeans tried rub-on potions of vinegar and opium. In 1660, a gruesome procedure dating back to prehistoric times known as trepanation (drilling holes in the skull) was popularized as a migraine treatment by the English physician William Harvey. Even then, doctors understood that swelling blood vessels in the head played a role in migraine pain. Erasmus Darwin (father of Charles Darwin) proposed yet another bizarre treatment: spinning the patient in a centrifuge to force the blood from the head to the feet.

Over the next two centuries, other theories about the origins of migraine arose, including the notion of migraine as a “nerve storm” within the brain, similar to epilepsy. But the first drugs specially designed to treat migraines, known as ergots, target the problem of dilated blood vessels, or vasodilation.

Ergots: Early migraine drugs

In 1938, researchers discovered that ergotamine — a drug derived from a rye fungus — could abort migraine attacks by constricting blood vessels, which led to the development of the drug dihydroergotamine (DHE). Today, doctors rarely prescribe ergot-based drugs because they affect blood vessels throughout the body and therefore cause more side effects than newer medications. Ergots also take longer to work than newer drugs; however, their beneficial effects last longer, so users are less likely to suffer a headache recurrence.

Ergotamine suppository (Cafergot) or injectable dihydroergotamine (DHE 45) may be useful for severe headaches because they’re absorbed faster than ergots in traditional pill form. But the ergotamine suppository, the most widely prescribed agent, tends to cause nausea and vomiting. Apart from being unpleasant, an upset stomach hinders the absorption of medications.

Dihydroergotamine is less likely than ergotamine to lead to nausea and vomiting. It used to be available only by injection, which made it a less popular alternative to ergotamine. The newer nasal spray version, Migranal, although easy to administer, is much less effective than the injection or the ergotamine suppositories because the tissue lining the nose doesn’t absorb medication very well. In contrast, lung tissue takes up drugs very effectively, which is why researchers are working to develop an inhaled ergot-based drug.

Triptans: Today’s migraine mainstays

Drug developers created triptan drugs in an effort to make a “cleaner” ergot; that is, a medication that worked similarly but caused fewer side effects. By 1993, the first of these, sumatriptan (Imitrex) was approved by the FDA. First available only by injection, triptans are now available as pills, melt-in-the mouth tablets, and nasal sprays. Between 1996 and 2003, six new triptans hit the market. These drugs relieve pain far faster than ergots, with improvements within five minutes and complete relief within one to two hours. Experts now believe that triptans may also temper inflammation as well as constrict blood vessels.

In pill form, almotriptan (Axert), eletriptan (Relpax), rizatriptan (Maxalt), sumatriptan (Imitrex), or zolmitriptan (Zomig) can stop the headache within two hours, provided the drug is taken when the headache is still mild. Doctors stress the importance of taking the drug as soon as possible after your symptoms begin, because as the headache progresses, migraine can slow down the gastrointestinal functioning and the medications aren’t absorbed as well. Although naratriptan (Amerge) and frovatriptan (Frova) can take nearly twice as long to work, they have fewer side effects and are more effective in preventing the headache’s return within 24 hours. Sumatriptan and zolmitriptan come in nasal sprays that cut the medication’s absorption time to an hour, making them a good choice for more intense migraine headaches. An injectable form of sumatriptan can provide relief in as little as 15 minutes. It’s available in an automatic injector, allowing individuals to self-administer the drug, although many are hesitant to do so. The injection also tends to cause muscle tightness, which can worsen the headache or cause chest pressure.

If one triptan doesn’t work, another often will (although you may have to wait 24 hours before taking a different type). If your headache still isn’t completely relieved, taking aspirin or another NSAID—such as ibuprofen, naproxen sodium, or ketoprofen—along with the triptan may help. Another option is a drug that combines sumatriptan and naproxen sodium (Treximet), which was approved for migraines with or without aura in 2008. Studies showed that more people who took the drug for migraine pain experienced relief than those who took either sumatriptan or naproxen sodium alone.

When taking triptans, you may experience some mild side effects. The oral medications can cause a tingling in your fingers or tightness in your throat, while the nasal spray can leave a bad taste in your mouth. The injectable form of sumatriptan tends to cause more intense side effects. On the other hand, triptans don’t cause the nausea and vomiting common to the ergots.

The triptans are expensive, and 30% to 40% of the time, the headache returns within 24 hours. Depending on the dose, you may be able to take the same triptan again during a given 24-hour period, but you can’t take a different triptan or a similarly working ergot. Because triptans and ergots narrow blood vessels, taking them at the same time could lead to a heart attack. Not surprisingly, people with heart disease or uncontrolled high blood pressure shouldn’t take these medications at all.