With so many new medications to choose from in treating acute migraine headaches, a few tips on choice of medication follows. This is not an all inclusive list but rather some pearls on making that first (or second) choice:
Imitrex: A change in head position for the nasal form has recently occurred. The new recommendation is for the patient to hold the head level and NOT tip the head either way (so that the medication lands on the nasal mucosa and is absorbed in the nose rather than in the throat). In the oral form, the 50mg pill is now the recommended dose to start with and then if needed 25mg can be taken in 4 hours. It is also acceptable to mix and match the different forms of Imitrex in treatment of the same headache. For
example, a patient could give him/herself an Imitrex shot at 3am and then take a 25 or 50mg pill later that same day if the headache is still present but perhaps at a lower level.
Zomig: Use the 5mg pill for a severe migraine headache. The 2.5mg dosage is more appropriate if the patient's headache builds more slowly. Relief can be expected in one to two hours. Note this medication does cross the blood brain barrier so more side effects may be noticed than with other 5-HT1 receptor agonists.
Amerge: This pill is absorbed more slowly but has a longer half life than some. At the 2.5mg dose it may be good for headaches that last a long time such as the menstrual migraine. It is however effective within two hours and has minimal side effects.
Maxalt: This 5HT has a quick onset and the recommended dose is 10mg. It does however interact with propanolol and for those patients on that drug, use the 5mg dose. The Maxalt MLT form is ideal for those with severe nausea since the tablet "melts" in the mouth.
Migranal Nasal Spray: As a non 5HT drug this is worth trying for any migraine patient who can tolerate nasal sprays. The recurrence rate for headaches is about fifteen percent.
Last updated: December 5, 1998
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