Headache Abortive Medication Treatment

Abortive medications can reverse, stop (“abort”) or significantly relieve a headache that is beginning or is about to occur. The sooner that you use an abortive medication at the onset of a headache, the more effective they may be. Do not take abortive medication every day. Use it only “as needed.” Overuse of abortive medication contributes to rebound headaches. Talk to your health care provider if you think you are taking too much abortive medication. 

•  Antihistamines – Antihistamines such as hydroxyzine (Vistaril) and diphenhydramine (Benadryl) can be effective for relieving pain. They may also decrease nausea and can stop the side effects of other medications such as droperidol. Possible side effects include drowsiness, dry mouth, urinary retention and constipation. 

• Corticosteroids – Steroids work by decreasing inflammation around blood vessels during a headache attack. Steroid tablets are often given on a tapering schedule, or a long-acting steroid injection may be used. Take steroids with food, as they commonly cause upset stomach. Steroids may also lead to higher energy/trouble sleeping and changes in blood sugar levels (especially in people with diabetes). Long-term use of steroids can cause serious side effects. However, steroid use in headaches is normally limited to less than a week, making possible complications less likely. Steroids used for headache treatment include prednisone (Deltasone), dexamethasone (Decadron) and methylprednisolone (Medrol). 

• Depacon – When given by rapid intravenous (IV) infusion, valproic acid (Depacon) appears to have some added anti-pain properties that are not seen when given by mouth. Depacon may stop the actions of neurotransmitters which conduct pain signals. Side effects are rare. 

• Dihydroergotamine (DHE-45) – DHE-45 by mimicking some effects of serotonin, and to a lesser extent, by directly decreasing the size of blood vessels. Typically, a course of DHE-45 is every eight hours for a total of nine doses. If the first course of DHE-45 is not successful, it may be repeated. DHE-45 can cause stomach upset. So before having DHE-45, you may be given a medication that stops stomach upset (an “anti-emetic”). DHE-45 is similar to ergotamine. Both medications can cause tingling in the hands or lower legs, increased blood pressure and dry mouth. Examples are DHE-45 (injectable solution) and Migranal (nasal spray DHE-45).

• Ergotamine – This medication helps headaches by decreasing the size of enlarged blood vessels. Though widely used several decades ago, ergotamine use has significantly decreased. Today, more effective and better tolerated medications are available. Examples of some ergotamines include Bellergal-S (a combination ergotamine product) and Cafergot tablets. (Wigraine and Cafatine have been discontinued by the manufacturer.)

• Magnesium  – How intravenous (IV) magnesium stops a headache attack is not known. However, inhibition of blood vessel changes and decreased inflammation are thought to be involved. Side effects are few and tend to be mild. They include flushing of the face/neck and brief decreases in blood pressure. Magnesium deficiency has been suggested as a potential trigger of migraine attacks in some people. This problem can be treated with magnesium supplements taken by mouth (oral).

• Muscle relaxants – These medications help relax tense muscles and block the body’s perception of pain. While drowsiness is common, other side effects include muscle weakness, insomnia and vertigo. Examples of muscle relaxants include orphenadrine (Norflex), baclofen (Lioresal), metaxalone (Skelaxin), cyclobenzaprine (Flexeril), carisoprodol (Soma), chlorzoxazone (Parafon forte), tizanidine (Zanaflex) and orphenadrine with caffeine and aspirin (Norgesic Forte). Lioresal, flexeril and zanaflex can also be used as preventive medication.

• Non-steroidal anti-inflammatory drugs (NSAIDs) – NSAIDs decrease inflammation (release of chemicals that cause pain, redness and swelling) that can occur during a headache. All NSAIDs can irritate the stomach; therefore, always take them with food and plenty of water. Examples include ketorolac (Toradol), ibuprofen (Motrin), flubiprofen (Ansaid), Naproxen (Anaprox, Aleve), indomethacin (Indocin) and etodolac (Lodine). Cox-2 inhibitors (Celebrex), which are similar to NSAIDs, may also be used for treatment of headache pain and inflammation. 

• Opioids – Opioids, or “narcotics,” work on the body’s nervous system to block the perception of pain. Opioids should not be used daily. Use them only “as needed,” as they typically do not provide long-term headache relief. Possible side effects include drowsiness, constipation, upset stomach, low blood pressure and physical dependence. Some opioids used for chronic headache relief include dolophine (methadone), nalbuphine (Nubain) and butorphanel (Stadol injection and nasal spray). Poor choices for chronic headache treatment include Demerol, butalbital (Fiorinal, Fioricet, Esgic), morphine, hydrocodone products (Vicodin, Lortab, Norco), codeine products, oxycodone products (Percocet, Percodan). 

• Phenothiazines – The exact way that phenothiazines relieve headache is not completely understood, but is believed to be due to effects on the neurotransmitters. In addition to headache pain, phenothiazines can also relieve nausea and vomiting. Phenothiazines may cause drowsiness, low blood pressure and tremors. Phenothiazines used to treat headaches include droperidol (Inapsine), promethazine (Phenergan) and prochlorperazine (Compazine).

• Triptans – Triptans work by copying the effects of serotonin and restoring normal blood vessel size. If one triptan doesn’t provide effective relief for a headache sufferer, it is reasonable to try a different triptan. In special situations such as menstrual migraine, triptans can be used on more than two or three consecutive days. Side effects may include chest tightness, tingling and facial flushing. Your health care provider may give you an initial “test-dose” in his or her office to see what effects, if any, the medication will have on you. Some commonly used triptans are listed in the table below.

Drug	Form	Usual maximum dose	Injection Form	Nasal Spray	Onset of Action	Duration of action
Imitrex (sumatriptan)	Yes	200mg (tabs)	Yes	Yes	Rapid	Normally repeated in 2 hours
Maxalt (rizatriptan)	Yes (meltable)	30mg	No	No	Rapid	Normally repeated in 2 hours
Zomig (zolmitriptan)	Yes (meltable)	10mg	No	Yes	Rapid	Normally repeated in 2 hours
Axert (almotriptan)	Yes	25mg	No	No	Rapid	Normally repeated in 2 hours
Relpax (eletriptan)	Yes	40mg	No	No	Rapid	Normally repeated in 2 hours
Frova (frovatriptan)	Yes	5mg	No	No	Medium	Normally repeated in 2 hours
Amerge (naratriptan)	Yes	5mg	No	No	Slower	Normally repeated in 4 hours

 

Abortive Medications Used Primarily in Cluster Headache

 

• Anesthetics  – Liquid cocaine and lidocaine are commonly used. They stop nerves from sending pain signals. These medications have a short duration of action, sometimes only 15 minutes of relief. They are given in the nose, which allows the drug to physically contact the nerves. 

• Oxygen – Breathing oxygen through a mask can quickly increase the amount of oxygen delivered to the blood vessels in your head and result in blood vessel changes that stop a headache attack.