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|Acute Medications for Migraine Attacks - Detailed - Medical Animation
|MEDICAL ANIMATION TRANSCRIPT: When a migraine attack occurs, rescue medications can help ease your pain. Let's look at what happens in your brain during an attack and how different medications can affect this process. During an attack, your nervous system becomes overly activated. It stimulates trigeminal nerve pain fibers and blood vessels in your meninges, which are the tissues around the outside of your brain. When the pain fibers are stimulated, they release calcitonin gene-related peptide, which is abbreviated as CGRP, as well as other chemical messengers. CGRP causes blood vessels to dilate, which leads to throbbing pain. CGRP also activates your immune cells, such as mast cells and glial cells. They release cytokines that cause local inflammation. CGRP also sensitizes the trigeminal nerves, which play a part in sending signals back to your brainstem and onto the rest of your brain, resulting in more pain and other symptoms. Serotonin, another neurotransmitter, can perform a lot of functions through receptors found on the surface of different cell types. During a migraine attack, serotonin attaches to receptors 1B, 1D, and 1F on trigeminal nerves, which in turn instructs the nerves to block the production of CGRP. With less CGRP, there is less pain and inflammation in the meninges and the rest of the brain. Serotonin also calms a migraine headache by activating receptors 1B and 1D on blood vessels that prevent their painful swelling. The goal of migraine medications is to stop the migraine attack by interrupting the chemical processes causing it. Medications called triptans can mimic serotonin and bind to its 1B and 1D receptors on trigeminal nerves and blood vessels. Triptans reduce the amount of CGRP and constrict swollen blood vessels, resulting in reduced pain and inflammation during a migraine attack. But because the serotonin receptor 1B that causes blood vessel constriction is also found throughout the body, triptans can also cause heart strain, high blood pressure, and stroke. As a result, triptans must be used with caution in people with significant cardiovascular risks. There are seven different triptans, and they vary in how quickly they work and how long they last. How quickly they work also depends on whether they are delivered as a pill, nasal spray, or injection. New rescue medications don't constrict your blood vessels and don't have the risks that triptans do. For example, gepants are a group of small molecules that minimize migraine pain by blocking CGRP from binding to its receptors, primarily on nerve endings. Lasmiditan is the first of a different group of small molecules, called ditans. Lasmiditan works similarly to a triptan, except that it only activates the serotonin 1F receptors, which are located primarily on the trigeminal nerves, not blood vessels. Lasmiditan may cause drowsiness, so driving should be avoided for eight hours after taking it. Ergot medications, such as DHE, activate several serotonin receptors, like triptans. Ergot lasts longer than triptans, but they take more time to work and are harder to get into your body. They can be effective, but, like triptans, they cause blood vessel narrowing, which makes them risky for patients who are older. Particularly those with cardiovascular risks. Prostaglandins are chemicals in your body that can cause blood vessels to swell within and around your brain. They can also increase inflammation and your body's sensitivity to pain. Cyclooxygenase enzymes called COX-1 and COX-2 are critical in the production of prostaglandins. Non-steroidal anti-inflammatory drugs or NSAIDs such as ibuprofen and aspirin, block COX enzymes and therefore block prostaglandin production and pain. The NSAID, Celecoxib is less likely to cause gastrointestinal side effects such as nausea, heartburn, and ulcers than other NSAIDs because it only blocks COX-2 enzymes. Another rescue medication called butalbital is a type of barbiturate. Butalbital is often combined with caffeine, acetaminophen, or aspirin to treat migraine. But butalbital can be addictive and may cause many side effects, including upset stomach, vomiting, shaking, dizziness, drowsiness, trouble sleeping, and dry mouth. Taking a rescue medication as soon as symptoms start is important for quickly aborting a migraine attack and reducing the risk of the disease becoming chronic. But there is a danger with overusing rescue medications. Avoid using acetaminophen and NSAIDs more than 14 days a month. And avoid using triptans, butalbital, or ergots more than nine days a month. Frequent use of these medications can lead to a different type of headache called Medication-Overuse Headache. The efficacy of rescue medications is different for everyone. Finding the right ones for you involves trial and error. Some medications can be more effective when used in combination. For example, triptans, gepants, and ditans can be taken with NSAIDs. Adding a neuromodulator, having nerve blocks, or making lifestyle changes can also help to manage migraine symptoms. For more information about treatment for migraine, talk to your healthcare practitioner.
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Richard E. Seroussi M.D., M.Sc.
Diplomate, American Boards of Electrodiagnostic Medicine and PM&R
Seattle Spine & Rehabilitation Medicine
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Troy, Yeslow & Koeppel, P.A.
Fort Myers, FL
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Snyder Slutkin & Kopec
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David J. Dean
Sullivan Papain Block McGrath & Cannavo, P.C.
New York, NY