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THE TREATMENT OF MIGRAINE-PREVENTIVE TREATMENT WITH MEDICATIONS
When the frequency of the attacks precludes the safe use of the abortive antimigraine drugs, analgesics, and sedatives, the preventive approach becomes justifiable. These preventive medications can be taken daily without the same risks associated with daily use of abortive medications, although these drugs, as with all medications, possess potential hazards.
Mood-altering drugs?antidepressants and tranquilizers?are sometimes beneficial either alone or in combination with other medications when the headache frequency justifies a preventive approach. As mentioned above, it may not be the mechanism by which the medication tranquilizes or reduces depression that is important in controlling pain. Current evidence suggests that these drugs exert an influence on pain perception, independent of
then-other effects.
Current research has suggested that certain of the antidepressants, particularly amitriptyline (Elavil, Endep), may exert an antimigraine effect when taken daily, independent of any direct effect on mood.
Amitriptyline (Endep and Elavil), an antidepressant, has many effects upon the body, and its use requires occasional blood tests and physical examinations. Common side effects include dryness of the mouth, blurriness of vision, dizziness, sedation, tingling in the extremities, and various other symptoms (including weight gain) that your doctor should discuss with you. The drug should not be taken by persons with some forms of glaucoma, urination problems, or those who are taking certain other medications. Pregnant women should not take this drug.
Amitriptyline taken in relatively small dosages at bedtime may have an impressive effect in the prevention of muscle contraction pain as well. Amitriptyline can be used in conjunction with other migraine drugs.
Most individuals taking this drug experience few, if any, serious side reactions, and it is fast becoming an accepted adjunct in headache prevention.
Cyproheptadine (Periactin) possesses antihistamine properties, and it also counteracts the chemical serotonin, the substance that plays an important role in migraine. Cyproheptadine should not be taken if you have glaucoma or asthma, or by any patient who is pregnant or has urinary or certain stomach conditions. It should never be taken at the same time you are using certain antidepressant drugs, and you should avoid this drug if you are elderly or debilitated. Antihistamines may induce seizures in some children with epilepsy and, therefore, must be used cautiously if there is a history of epilepsy. This drug may be particularly apt to produce adverse reactions when combined with alcohol or any depressant medication. Common undesirable effects of cyproheptadine include drowsiness and a feeling of dizziness and unsteadiness. Many patients complain of increased appetite and subsequent weight gain. Nevertheless, cyproheptadine is considered by many headache authorities to be a safe and effective drug for many headache types, particularly childhood migraine.
Bellergal, a compound drug, includes small amounts of ergotamine, a barbiturate tranquilizer, and an antinauseant. Because Bellergal contains such a small amount of ergotamine, it may be given daily for several months without significant risk of producing toxicity. But, as with other medications containing ergotamine, you should not use it if you have blood vessel or coronary artery disease, high blood pressure, kidney or liver disorders, or if you are pregnant. Because many antinauseants have an adverse effect on glaucoma, this drug should not be used by anyone suspected of having or known to have this condition. The most common side effects of Bellergal include dry mouth, drowsiness, and blurred vision.
Propranolol (Inderal), a medication that blocks the effect of the body’s adrenalin on certain tissues, has now become recognized as an important drug in the prevention of migraine. Numerous studies, as well as current clinical experience, have shown impressive benefit in many patients. Propranolol is also being used for certain heart conditions, high blood pressure, and some other medical disorders as well. Propranolol cannot be used if you have asthma, severe allergic conditions, significantly slowed heart rate, very low blood pressure, uncontrolled diabetes, severe hypoglycemia, heart failure, or if you are pregnant.
During treatment with propranolol, your heart, blood pressure, and pulse rate should be watched and evaluated regularly. Although this drug is generally very well tolerated, some of the potential side effects include fatigue and gastrointestinal disturbances. Mild weight gain and some fluid accumulation have been reported. Unlike many other medications that are helpful against migraine, propranolol does not usually sedate the patients using it.
Methysergide (Sansert) simulates the action of serotonin, the chemical we have previously mentioned as important in the production of migraine headaches. This drug can be potentially hazardous when taken regularly for a prolonged time. It can produce scar formations in various organs, including the heart, lung, and around the kidneys. Methysergide can impair blood circulation to the extremities, and it can cause blood abnormalities and muscle cramps. Chest and abdominal pains, stomach upset, insomnia, dizziness, and hallucinations may also occur. These reactions understandably limit the usefulness of methysergide. However, most complications are reversible when the drug is withdrawn or the dose is reduced. You should not take this drug during pregnancy, or if you have poor circulation, heart disease, high blood pressure, or lung, liver, or kidney trouble. Despite its risks, methysergide has proved to be a very effective preventive antimigraine drug in many individuals. Most of the serious hazards of the drug can be avoided if it is used for only three or four months at a time and is then followed by a one-or
two-month “drug holiday” in which no methysergide is taken.
It may come as a surprise to you that aspirin is mentioned in a list of preventive medications, since it is a simple analgesic and frequently fails to abort the already present migraine. But as we said earlier, current research in migraine is focusing on the possible higher-than-average risk of heart attacks and strokes in some migraine patients, particularly those with the classical migraine type. This risk may have something to do with increased platelet stickiness (platelets are clotting particles in the blood). Among aspirin’s medical properties is an antiplatelet, anticlotting action. In experimental settings, aspirin is being given daily (one to two tablets per day) along with other drugs to combat this increased platelet stickiness. It remains to be seen whether aspirin has a reliable and beneficial effect on this problem or on preventing, as opposed to aborting, the headache of migraine.
Clonidine (Catapres) is yet another drug used to prevent migraine. It is used primarily as an agent to control high blood pressure, but effectiveness in controlling migraine has been
suggested by some medical reports. Side effects include dry mouth and drowsiness. Mild gastrointestinal distress, weight gain, and vivid dreaming are also reported. The drug should be reduced slowly when discontinued. Use during pregnancy should be avoided.
The substance pizotifen (Sandomigran) is not available in the United States but is in Canada. This substance has serotonin-blocking properties and other effects on the amines. Although we do not have personal experience with the drug, scientific reports suggest effective control of migraine in many patients. The most common side effects reported have been weight gain and fatigue. The drug is related to cyproheptadine and some of the antidepressants, and as with these and all drugs, its use during pregnancy must be avoided.
We have discussed the important precautions concerning the use of some of these medications, along with a few of their potential side effects, because we wish to emphasize to you once again that most medications are potentially hazardous, whether they require a prescription or not. Nevertheless, when taken with caution and with regular medical supervision, these medications can make the life of a migraine patient more enjoyable. The adverse reactions we have mentioned, particularly the serious ones, may have occurred in only a small percentage of the many thousands of people who have safely taken these drugs. Most of these medications will not produce significant adverse reactions in the vast majority of people. Nevertheless, it is best to avoid medication whenever possible. When their use is necessary, you should be alert to the possible consequences, even though serious adverse reactions are relatively unlikely.
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