Migraine Arsenal Essentials: Rescue Treatment
A complete Migraine arsenal doesn’t contain just one type of treatment. It contains three main types:
Rescue treatments are treatments we use when we get a Migraine attack and our abortive treatment fails or if, for some reason, we cannot use any of the abortive treatments.
Some doctors tell their Migraine patients about all three categories of treatment, but it’s painfully obvious from online conversations and the questions we receive here that too many doctors don’t. In some cases, this occurs because, in today’s hectic medical practices, there’s often too little time for doctors to have many discussions with us or to spend time on patient education.
A World Health Organization (WHO) report points to another probable reason - the doctors themselves don’t know enough about treating Migraine. The shocking report revealed that, worldwide, formal undergraduate medical training included just four hours about Migraine and all other headache disorders; specialist training included 10 hours.
The objectives of rescue treatments are:
- To give us the tools to end our Migraines as soon as possible
- To “rescue” us when our first-line acute medications fail
- To treat our Migraines at home, without needing to resort to the emergency room or an urgent care center
Medications used for rescue:
The most frequently used rescue medications include:
- prescription-strength NSAIDs such as indomethacin (Indocin) and ketorolac (Toradol)
- antiemetic medications such as prochlorperazine (Compazine), promethazine (Phenergan), metoclopramide (Reglan), and ondansetron (Zofran)
- muscle relaxants such as carisoprodol (Soma), metaxalone (Skelaxin), tizanidine (Zanaflex)
The following medications are less often used for rescue because contain opioids or barbiturates. Research has shown that any use of opioids or barbiturates increases the risk of episodic Migraine progressing to chronic Migraine and makes it more difficult to get chronic Migraine back down to episodic.
That’s not to say that there’s no place for opioids or barbiturates in migraine treatment, but careful consideration and specific “rules” for their use must be in place. Opioids and barbiturates are prescribed for rescue usually for patients who don’t need to use them very frequently. Frequent or daily opioid therapy is prescribed only for a very small percentage of migraineurs who have chronic Migraine that is also intractable, which means that their Migraines also don’t respond to treatment.
Other medications used for rescue, but less frequently:
- butalbital compounds: Fiorinal, Fioricet, etc. (with or without codeine)
- acetaminophen with codeine, oxycodone, or hydrocodone such as Vicodin, Percocet, Tylenol #3
- oral opioids such as hydromorphone (dilaudid), tramadol (Ultram)
- injectable medications such as nalbuphine (Nubain) or meperidine (Demerol) to be used at home in emergencies
A Migraine specialist’s point of view on rescue medications:
David Watson, M.D., a UCNS certified Migraine specialist and HealthCentral contributor, commented:
"Rescue treatments are often not the ideal treatment, as they can cause sedation or other side effects, which is why they are used as rescue and not as our first-line treatments. If patients expect their doctors to work with them on rescue treatments, they should also be willing to do the hard work of trigger avoidance, sleep hygiene, caffeine reduction, etc. Too many patients and doctors just look to find another pill rather than looking to lay the groundwork for real improvement. If your rescue treatment is needed more than once or twice per month, you might want to question your abortive and even your preventive."
For effective Migraine management, we need to have a treatment plan that covers us in as many circumstances as possible. Emergency rooms and urgent care facilities aren’t our best options for Migraine treatment. We may not always be able to avoid them, but with rescue treatments available, going to the ER or urgent care should be a rare event.
If your Migraine management plan doesn’t include rescue treatments, please talk with your doctor. He or she should be able and willing to discuss the options with you and devise a good rescue plan. If not, perhaps it’s time for a new doctor.
Email interview with Dr. David B. Watson. December 8, 2014.
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