This blog is written by the staff at Migraine Meanderings as part of an educational project sponsored by Tonix Pharmaceuticals, the makers of Tosymra & Zembrace
Does your migraine pill work every time? Do you experience nausea, vomiting or abdominal pain during your migraine attacks? Have you ever woken up in the middle of the night or early morning with a full-blown migraine attack? What about fast-escalating attacks where one minute you feel fine and then suddenly your head seems to be exploding with a migraine before you’ve even had a chance to do anything about it? You may even find yourself wondering if you will have to go to the ER or urgent care because “nothing is working”! These are really important questions, and sadly ones that many doctors do not ask their patients when considering the best treatment options to manage their migraine attacks.
The Goals of Acute Migraine Treatment
Every patient with migraine has likely been told by their doctor to use their acute migraine treatment at the first sign of attack symptoms. However, there are additional factors that are also important to consider when deciding on acute treatment options:
- How fast it works: Migraine attacks need to be treated quickly and correctly. If the medication is not fast-acting, or is not able to be properly absorbed, the attack will take longer to treat or may even end up requiring emergency treatment.
- How safe & tolerable it is: All medications have side effects. The goal is to find a safe and effective treatment with the fewest intolerable side effects given your personal preferences and any other medical conditions.
- Impact on quality of life: When acute migraine medicines are effective, symptoms are relieved quickly. Shorter attacks mean fewer missed school and work days and more time to spend with the people and activities you enjoy.
Four Challenges to Achieving These Goals
While everyone experiences migraine attacks slightly differently, and likely even has more than one type of attack themselves, there are a few common factors that make achieving our treatment goals challenging:
Challenge #1 – Nausea and Vomiting: Both nausea and vomiting are common migraine symptoms. A large survey in the United States, completed by 29,727 participants, reported that 73% of patients with migraine experienced nausea during attacks, and 29% experienced vomiting. Surprisingly, these symptoms were often reported to be worse than the head pain itself.
The Bottom Line?: the efficacy of oral migraine medication alone can be impacted by nausea and vomiting
Challenge #2 – Gastroparesis: Gastroparesis (GP) is a disorder that delays gastric emptying, and is also known as stomach paralysis. The condition causes the muscles and nerves in the stomach not to work correctly. This slows down the digestion of food, making it harder for the food to move from the stomach to the small intestine. GP can cause symptoms such as feeling full quickly while eating, loss of appetite, indigestion, upper abdominal pain, nausea, and vomiting. You may also have constipation and a bloated stomach, and if you have diabetes then GP can even impact your blood sugar levels. Unfortunately, some migraine medicines can worsen gastroparesis, as well as the semaglutide GLP-1 class of medications used for type 2 diabetes and obesity (both of which are comorbid conditions with migraine).
The Bottom Line?: Gastroparesis, a symptom of migraine, can slow down the rate of absorption of oral migraine medications
Challenge #3 – Wake-Up Migraine: A recent poll in the Migraine Meanderings Facebook Support Group showed 52% of people in our community saying they often get woken up by a migraine in the middle of the night or early morning, and an additional 35% saying that sometimes happen. Unfortunately, this means that the time for “early treatment” at the start of the attack is likely impossible because that time already passed while the person was asleep. “Wake-up migraine” attacks are often already well under way, or even full-blown and disabling.
The Bottom Line?: It may be too late to use oral medication by itself to effectively treat a migraine attack that begins while the patient is asleep
Challenge #4 – Fast-Escalating Migraine Attack: Rapid onset attacks present a specific challenge to treatment. In some cases these are actually thunderclap headaches, which can be a medical emergency. Thunderclap headaches come on suddenly and cause intense pain, 10 out of 10 level within 60 secs to 5 minutes. However, in some cases migraine attacks themselves escalate so fast that it is challenging to start treatment quickly enough for oral medication to be quickly absorbed.
The Bottom Line?: Oral medication may not be absorbed quickly enough to be effective by themselves for rapid onset migraine attacks
The key question to ask yourself, as a person who lives with migraine, is: Do I need to have a non-oral medication available to use for at least some of my migraine attacks, in addition to any oral medications already prescribed? Should I consider a nasal spray or injection?
Is a Non-Oral Acute Migraine Medication Going to Help Me?
If you are reading this blog and have been thinking something like: “Yikes, I wake up with migraine!” or “I get nauseous and vomit during attacks!” or even, “I hate going to the ER, but sometimes I don’t seem to have any other choice!” Then it’s time to talk to your doctor about including a non-oral medication, such as a nasal spray or injection, to your migraine treatment plan.
Ask your doctor to complete a Migraine Action Plan that will help you better manage your migraine. The Migraine Action Plan includes a preventive protocol, and explains which acute treatments to use, when to use them, what the right dose is, whether you can combine multiple options, and what the best option is based on your current symptoms or stage of the attack. You can download a free printable Migraine Action Plan HERE to take to your doctor!
Talk With Your Doctor About Treatment Options
The good news is that as much as there are many different ways a migraine attack can present, there are also many treatment options and combinations of options that can be tried to help restore your quality of life. So if your migraine pill doesn’t always work, you experience nausea or vomiting, get woken up with full-blown attacks, or have rapid onset migraine, talk with your doctor. Ask them if you can try a non-oral medication and walk through a personalized Migraine Action Plan. This way, you can leave their office confident in your treatment options. The following are a few questions you can use to start the conversation with your doctor:
- Do I consistently feel better within 1-2 hours after taking my current medication?
- During attacks, does my pain build up slowly or fast?
- Do I ever wake up with a migraine attack during the night or early morning?
- Do I experience nausea and/or vomiting during attacks?
- Do other medical conditions or medications affect your digestive system?
- Which would be the best non-oral medication to try given my specific situation?
Let us know…
Have you tried a non-oral migraine treatment? Has your doctor ever offered to prescribe a nasal spray or injection? If so, has this helped you better manage your migraine attacks?