Doctor on Call: Acute Migraine Treatment: When Side Effects Limit Effectiveness
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Samuel, a 23-year-old male in the midst of a marketing internship and living in Nashville, writes:
I’ve had migraines my entire life. I can remember my parents taking me to emergency rooms when I was just a kid because the nausea and vomiting I had with my migraine headache was so bad that I needed intravenous fluids for dehydration. None of the usual over-the-counter meds did anything. I would just go in my bedroom, turn off the lights and hope I could get to sleep.
When I was 16 I finally saw a doctor who prescribed sumatriptan pills and shots, and it was like a miracle. If I could catch the headache early enough, the pill would stop it. If I was late or I already felt like I couldn’t keep anything down, I would use the shot. It was great!
The only problem was the pills would knock me out. And the shots were even worse. My headache would be gone or almost gone, but otherwise I felt limp as a dishrag and barely able to get out of bed… like I had a bad hangover, but without the headache. Now that I’m working I can’t just take a pill or give myself a shot and go lie down. I have to wait until I get home, and by that time the headache may be so bad that it’s like when I was a kid. Nothing helps until I go to sleep, and even then I may wake up in the morning with the headache still there and so bad that I have to call in sick.
What can I do? I tried Maxalt [rizatriptan], but the same thing happened. Between the headaches and the side effects from the medicine, I’m afraid I’ll screw up my internship and have no chance of getting asked to stay on.
The Doctor’s Reply:
A rough situation. This young man with a long history of migraine attacks that can be disabling finally finds a medication that works but hesitates to use the medication because it interferes with his performance on the job.
This is a surprisingly common story for headache subspecialist to hear. For a long time we’ve wondered whether these “hangover” symptoms represent a side effect of the triptans or whether the triptans are effectively treating the headache phase of the migraine episode and pushing patients along to the “postdrome” phase. As regards the latter, many migraineurs report prodromal symptoms that signal a headache is on the way, some then develop aura, headache typically follows the aura and the postdrome follows the headache phase.
Then came rimegepant (Nurtec) and ubrogepant (Ubrelvy). As “gepants” that oppose the action of calcitonin gene related peptide (CGRP), both work on protein receptors within the biologic “circuitry” of migraine that are different from the serotonin receptors where the triptans act. At least a portion of patients like Samuel who respond to the triptans but experience what sound precisely like postdromal symptoms may find Nurtec or Ubrelvy to be just as effective for headache relief but free of the unwanted “hangover” that follows the headache relief. At least in those patients, it would seem logical to assume that the symptoms experienced represent side effects of the triptan rather than symptoms of the migraine postdrome.
One last word: delaying treatment of an acute migraine headache is almost always a bad idea. The further an acute migraine episode progresses clinically and biologically, the more difficult it is to turn off the “circuitry” and stop the episode. Delayed treatment is often associated with partial headache relief, and partial headache relief is associated with an increased likelihood of early headache recurrence…back to a moderate or severe level of intensity. If you are delaying treatment because of side effects associated with your “rescue” medication, it may be time for a switch. And now there are more options.
