When we discuss migraine medications and treatments, we break them down into three categories:
- Preventive treatments: generally used daily to reduce the frequency and severity of migraine attacks.
- Abortive treatments: those treatments used to stop a migraine attack when it occurs. These are not pain medications. They work to stop the migraine itself, thus stopping the symptoms as well. The abortive treatments include:
- Triptans: Imitrex (sumatriptan), Maxalt (rizatriptan), Zomig (zolmitriptan), etc.
- Ergotamine medications such as D.H.E 45 and Migranal Nasal Spray.
- Midrin "equivalents:" Brand name Midrin has been permanently discontinued, but equivalent medications are available.
- Rescue treatments: those treatments used when abortives fail or cannot be taken. A primary goal of having rescue treatments is to prevent patients from needing to seek care in emergency rooms and urgent care facilities.
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.
I recently had yet another online conversation with a migraine patient who had to go to an urgent care facility for a bad migraine Thanksgiving evening. She reported that she received no help, and went home no better off than when she went. One would think that, in this era of medical advances, this wouldn't happen, but it does happen, and it happens all too often.
About Rescue Treatments:
- Abortive treatments can fail. They don't work every time, even in patients for whom they usually work well.
- Rescue treatments are intended to "rescue" us when abortive treatments fail.
- Rescue treatments are also used by people for whom abortive treatments can't be used - people with a history of stroke or heart issues, for example.
- Another purpose of rescue treatments is to keep us out of emergency rooms and urgent care facilities, for several reasons:
- Time. Rescue treatments, which are used at home, can be used as soon as we determine that our abortive treatments have failed - subject, of course, to our doctors' instructions. That removes the time of getting to an ER or urgent care facility from the equation, so we get relief sooner.
- Getting the treatment our doctors recommend. Most ERs and urgent care facilities don't contact our doctors, so we're given the treatment the doctor there decides to give us, which may not be at all what our own doctors would recommend.
- The doctors in ERs and urgent care facilities may know very little about migraine and don't truly know what treatments are best for us.
- Dignity and comfort. Going to ERs and urgent care facilities can be a nightmare. Some health care professionals in that setting tend to see people who present with migraine as drug seekers. This is somewhat understandable because migraine, headache, and back strain are the chief complaints used by people seeking drugs because there are no tests to confirm those complaints. It's also obvious that it's more comfortable for us to treat quickly at home rather than enduring the travel, noise, lights, etc., of an ER or urgent care visit.
- All of us should have rescue treatments available to us.
- Rescue treatments facilitate appropriate treatment in a timely fashion.
Medications Used for Rescue Include:** Frequently used:**
- Prescription-strength NSAIDs such as indomethacin (Indocin) and ketorolac (Toradol).
- Antinausea medications such as prochlorperazine (Compazine), promethazine (Phenergan), metoclopramide (Reglan), and ondansetron (Zofran).
- Muscle relaxants such as carisoprodol (Soma), metaxalone (Skelaxin), tizanidine (Zanaflex).
Less frequently used:
The following medications are less often used for rescue because they're 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 are 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.
- Butalbital compounds: Fiorinal, Fioricet, etc. (with or without codeine)
- Acetaminophen with codeine, oxycodone, or hydrocodone such as Vicodin, Percocet, Tylenol #3.
- In some cases, doctors will prescribe injectable medications such as nalbuphine (Nubain) or meperidine (Demerol) to be used at home in emergencies.
From a Migraine Specialist's Point of View:
Dr. David Watson, director of the headache center at West Virginia University and a 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."1
Rescue treatments are as important in our treatment plans as preventive and abortive treatments. Each of us should have a plan (and treatment) for times when our abortive treatments fail. Emergency rooms and urgent care facilities are generally not good options for migraine treatment. One urgent care facility in my area refuses to treat migraine or headache at all because they don't have the imaging equipment necessary to rule out physical issues such as tumor, stroke, and aneurysm. Some doctors will not prescribe opioids or barbiturates for migraine because they can make matters worse. They're not being mean or uncaring; they're following, "First, do no harm."
If your migraine management plan doesn't include rescue treatments, 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.
Interview. Dr. David B. Watson with Teri Robert. December 8, 2014.
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