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Ergotamine (Ergot)
Drugs containing ergotamine (commonly called ergots) constrict smooth muscles, including those in blood vessels, and are useful for migraine. They were the first specific anti-migraine drugs available. Ergotamine is available in the following preparations:
- Dihydroergotamine (DHE) is an ergot derivative. It is administered as a nasal spray form (Migranal) or by injection, which can be performed at home.
- Ergotamine itself is available in oral tablets (Ergomar, Wigraine, Ercaf) and in rectal suppositories (Cafergot). Cafergot, Wigraine, and Ercaf contain caffeine.
Their role since the introduction of triptans is now less certain. Only the rectal forms of ergotamine are superior to rectal triptans. Injected, oral, and nasal-spray forms are all inferior to the triptans. Ergotamine may still be helpful for patients with status migrainous or those with frequent recurring headaches.
Side Effects. Side effects of ergotamine include:
- Nausea
- Dizziness
- Tingling sensations
- Muscle cramps
- Chest or abdominal pain
The following are potentially serious problems:
- Toxicity. Ergotamine is toxic at high levels.
- Adverse effects on blood vessels. Ergot can cause persistent blood vessel contractions, which may pose a danger for people with heart disease or risk factors for heart attack or stroke.
Internal scarring (fibrosis). Scarring can occur in the areas around the lungs, heart, or kidneys. It is often reversible if the drug is stopped.
The following patients should avoid ergots:
- Pregnant women. Ergots can cause miscarriage.
- People over age 60.
- Patients with serious, chronic health problems, particularly those of the heart and circulation.
Lidocaine
Nasal drops containing lidocaine, a local anesthetic, can provide effective pain relief within 15 minutes for many migraine sufferers. However, lidocaine has certain downsides:
- It is rather difficult to administer. Patients must be lying down with their head dangling.
- The headache often relapses in an hour, and other drugs must then be used.
- Side effects include unpleasant taste, burning sensation, and facial numbness.
However, the drug does not cause drowsiness or heart rhythm disturbances as some other migraine treatments do. Its fast effectiveness and safety make it a promising first drug during a migraine attack. It should not be used for any other form of headache.
Opioids
If the pain is very severe and does respond to other drugs, doctors may try painkillers containing opioids [morphine, codeine, meperidine (Demerol), or oxycodone (Oxycontin)]. Butorphanol is an opioid in nasal spray form that may be useful as a rescue treatment when others fail. Several such drugs use combinations of opioids plus NSAIDs (ibuprofen or aspirin) or acetaminophen. One study reported that about half of patients who start opioid therapy for migraine respond well and the benefits persist over time. In a major 2002 analysis of over 800,000 headache cases, Demerol was the most commonly administered drug (30% of migraine cases). Nevertheless, experts do not recommend opioids as first-line therapy for migraine sufferers.
Side Effects. Side effects for all opioids include drowsiness, impaired judgment, nausea, and constipation. There is a risk for addiction, and they can become ineffective with long-term use for chronic migraines. Such drugs should not be prescribed for patients at risk for drug abuse, including those with personality or psychiatric disorders.
Drugs Used for Nausea and Vomiting
Metoclopramide (Reglan) is used in combinations with other drugs to treat the nausea and vomiting that occurs with other drugs and with the condition itself. Metoclopramide and other anti-nausea drugs, such as domperidone (Motilium), may help the intestine absorb migraine medications.
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