Best Pain Medication for Familial Hemiplegic Migraine?

Health Professional

Full Question:

What pain medication on the market today can give a Familial Hemiplegic Migraine sufferer the most relief from a pain level number 10 migraine? Judy.

Full Answer:

Dear Judy:

Hemiplegic migraine (HM) is an uncommon but well-recognized form of migraine. Typically, one-sided weakness occurs with more typical migraine features, but sometimes the weakness can last much longer than the other symptoms. There are both sporadic and familial forms:  Sporadic just means that there is not a family history of HM where Familial (FHM) refers to a genetic basis. There are a few identified genes that lead to FHM but likely many others that have yet to be discovered. You can read more about HM in Sporadic and Familial Hemiplegic Migraine – The Basics.

Now, to your actual question. While the triptans and ergotamines have largely been considered the best targeted medications for migraine, there remains concern about their use in HM. Unfortunately, much of this concern is related to previous theories of migraine and migraine aura being related to vascular changes. In particular, it was believed that aura was caused by constriction or narrowing of blood vessels, and that if this was severe enough to cause weakness, then using medications with a vasoconstrictive effect would be dangerous. Therefore, HM patients were not studied in the original trials of these medications. Consequently, they now carry a contraindication to their use in HM. As our understanding of the mechanisms of migraine and aura have improved and moved away from a direct vascular effect, some headache and migraine specialists have begun to use these meds in HM despite the labeling. This also applies to the Midrin equivalent medications since the isometheptene mucate they contain has vasoconstrictive actions.

Let's assume, however, that triptans and ergots are not an option for you. What do you do instead? There are a number of options, and you likely need at least a two-pronged approach:  Acute abortive and rescue medications (you may also benefit from preventive meds). Non-steroidal anti-inflammatory drugs (NSAIDs) can be a good option for many. While over-the-counter NSAIDs may not be strong enough, there are a number of good, potent, prescription ones that can be. Diclofenac, which is FDA approved for migraine in Cambia, a powdered form, and ketorolac are two that I often use, but many others are available. Often these need to be combined with supplementary medications, such as anti-nausea medications like prochlorperazine or metoclopramide, and/or anti-histamines such as diphenhydramine or hydroxyzine. Taking these medications early in the progression of the migraine attack can often keep it from ever becoming a 10/10 on the pain scale. If these fail, rescue medication may be necessary. Some options for rescue medications include anti-nausea medications (if not already used), atypical antipsychotics like Seroquel (for the sedating effects), and some muscle relaxers like tizanidine.

In worst-case scenarios, your physician may prescribe a limited number of opiate medications. Typically these are not recommended in headache disorders because evidence suggests that opiates lead to more intractable headaches in the long run, but sometimes, when very well limited and controlled, they can be a useful tool in the management of severe migraine, especially in HM when other, better treatments carry contraindications.

Thanks for your question,
David Watson, MD

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About Ask the Clinician:

Dr. David Watson is a UCNS certified migraine and headache specialists and director of the Headache Center at West Virginia University. He and Lead Health Guide Teri Robert, team up to answer your questions about headaches and Migraines. You can read more about _ Dr. Watson_ or more about _** Teri Robert** _.

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