Medication For Persistent Pain: Anti-Migraine Medications

What are Anti-Migraine Medications?

Anti-migraine medications are drugs used to prevent or treat migraines, which are recurrent headaches often accompanied by nausea, vomiting, and sensitivity to light or sound.

In the case of chronic migraines, these include prophylactic medications taken regularly to reduce the frequency, severity, and duration of migraines.

What are Beta Blockers?

Beta blockers such as propranolol and metoprolol are a class of medications that block the effects of the stress hormones adrenaline and noradrenaline on the beta receptors of the heart and blood vessels. This action helps lower heart rate and blood pressure, making beta blockers useful in treating cardiovascular conditions.

Although beta blockers were initially developed for heart conditions, they are widely used to prevent migraines. Their ability to prevent migraines is thought to stem from their effects on the nervous system, blood vessels, and neurotransmitters.

Migraine headaches are associated with the dilation and constriction of blood vessels in the brain. Beta blockers help regulate these changes by stabilising blood vessel activity, which reduces the likelihood of migraine onset.

They also reduce the excitability of nerve cells in the brain that may trigger migraines. By calming overactive nerve pathways, they may prevent the chain reaction that leads to a migraine.

Stress is a known migraine trigger. Beta blockers, by dampening the body’s response to stress, can lower the release of adrenaline and other stress hormones that might initiate migraines.

Beta blockers are typically used as a preventive treatment for people who experience frequent or severe migraines (more than 2-3 migraines per month). Studies show that beta blockers can reduce the frequency of migraines by 50% or more in many patients. However, they are not used for acute treatment during a migraine attack.

What is Topiramate?

Topiramate is an anticonvulsant (anti-seizure) medication that is also widely used as a preventive treatment for migraines. It works by stabilising the electrical activity in the brain and affecting neurotransmitter pathways that may be involved in migraine development. While it does not stop migraines once they have started, it helps reduce the frequency, duration, and severity of migraines when taken regularly.

Topiramate is taken daily as a preventive treatment, typically prescribed to individuals who experience frequent or disabling migraines. It is not used to treat a migraine once it has begun but rather to reduce how often they occur.

Studies have shown that topiramate can reduce the frequency of migraines by 50% or more in many patients. It typically takes a few weeks to begin working, and doctors often start with a low dose and gradually increase it to minimise side effects.

What is Pizotifen?

Pizotifen is a medication primarily used as a preventive treatment for migraines and cluster headaches. It belongs to a class of drugs known as serotonin antagonists, and it works by blocking serotonin receptors in the brain, which can help reduce the frequency and severity of migraine attacks.

Pizotifen is generally prescribed for patients who experience frequent or severe migraines. It is not effective for treating an acute migraine attack but is taken regularly to help prevent migraines from occurring.

Pizotifen has been shown to reduce the frequency of migraines in many patients. The full effect may take several weeks to become apparent, so it is important for patients to be patient and consistent with their medication regimen.

Pizotifen can be an effective option for individuals who suffer from migraines and may not respond to other preventive treatments.

What is Gabapentin?

Gabapentin is an anticonvulsant medication primarily used to treat epilepsy and neuropathic pain. While it is not a first-line treatment for migraines, it has been utilised as a preventive treatment for migraines in some patients, particularly those who experience migraines accompanied by nerve-related pain or those who have not found relief with other medications.

This drug is typically prescribed for patients who experience frequent migraines and have not responded well to other preventive treatments. It may be particularly helpful for those with a history of anxiety, chronic pain conditions, or medication overuse headaches.

Studies on the effectiveness of gabapentin for migraine prevention have shown mixed results. Some patients report a reduction in the frequency and severity of their migraines, while others may not experience significant benefits. It is generally considered less effective than other preventive medications such as beta blockers or antiepileptic drugs like topiramate.

Gabapentin can be an option for migraine prevention in select patients, particularly those who have not found relief with first-line treatments.

What is Amitriptyline?

Amitriptyline is a tricyclic antidepressant that is commonly used to treat depression, anxiety, and certain types of chronic pain. It is also effective as a preventive treatment for migraines and is often prescribed for patients who experience frequent or severe migraine attacks.

Amitriptyline is typically prescribed for patients who experience migraines more than two to three times a month or who have migraines that are severe enough to interfere with daily activities. It is taken daily as a preventive measure rather than as a treatment for acute migraine attacks.

Research has shown that amitriptyline can significantly reduce the frequency and severity of migraines in many patients. It may take several weeks to notice the full benefits of the medication, so patients are often advised to be patient and consistent with their treatment.

Amitriptyline can be an effective preventive treatment for migraines, especially in individuals who have not found relief with other therapies.

What are CGRP Blockers for Migraine Management?

CGRP blockers or calcitonin gene-related peptide blockers are a class of medications used for the prevention of migraines. They target CGRP, a neuropeptide involved in the development of migraine attacks.

During a migraine, CGRP levels increase, leading to dilation of blood vessels in the brain, activating inflammatory pathways.

There are several types of CGRP blockers. Monoclonal antibodies work in one of two ways to prevent migraines or treat acute migraines:

1. They block the receptors in and around the brain where cGRP must attach to work (Aimovig, Nurtec)
2. They bind to cGRP ligand and prevent it from working (Emgality, Ajovy, Vyepti)

They are administered as subcutaneous and intravenous injections, and they are typically used for chronic or frequent or episodic migraines.

CGRP medications currently available in Australia:

• erenumab (Aimovig)
• fremanezumab (Ajovy)
• galcanezumab (Emgality)
• eptinezumab (Vyepti)
• rimegepant (Nurtec)

All of these medications are designed to be used as preventatives to reduce the number of attacks, while Nurtec may be used as either a preventative and/or an abortive when attacks occur.

CGRP blockers are effective for patients who don’t respond to or cannot tolerate triptans or similar traditional migraine treatments. They have few side effects or interactions with other medications.

What are Triptans and Antiemetics?

Triptans such as sumatriptan and rizatriptan are migraine-specific medications that act as serotonin receptor agonists to constrict blood vessels and reduce inflammation, effectively relieving acute migraine symptoms. Triptans need to be taken within half an hour of commencement of headache/ aura for them to be effective in mitigating the migraine. They are recommended to be used no more than twice a week. If more is required, then patients are commenced on preventative migraine therapy to reduce the frequency of headaches.

Antiemetics are medications that prevent or treat nausea and vomiting by blocking specific pathways in the brain and gastrointestinal system, often used in conditions like migraines, motion sickness, or chemotherapy-induced nausea.

Together, triptans and antiemetics are used to treat acute migraines because they address different aspects of the condition. They may also be combined with high dose aspirin to manage acute migraine effectively.

Triptans are specifically designed to treat migraines by targeting the underlying cause—dilated blood vessels and nerve inflammation. They act as serotonin receptor agonists (5-HT1B/1D). Triptans constrict blood vessels and reduce the release of inflammatory neuropeptides in the brain.They are available in various forms (tablets, nasal sprays, subcutaneous injections) to accommodate different patient needs.

Note that triptans can cause side effects including tingling, dizziness, or tightness in the chest and are not recommended for use in patients with cardiovascular disease due to vasoconstrictive effects.

Antiemetics like metoclopramide, prochlorperazine, and ondansetron help manage nausea and vomiting associated with migraines, which can make it difficult to take or absorb oral medications.They block dopamine or serotonin receptors involved in nausea pathways. Some antiemetics may also enhance gastric motility, helping oral medications absorb more effectively.

Combining triptans with antiemetics can provide faster relief by addressing both pain and nausea, improve the effectiveness of oral medications by reducing gastric stasis (common during migraines, and enhance overall comfort and medication adherence.

What is Lignocaine Infusion Treatment for Refractory Migraines?

Lignocaine infusion treatment is a therapeutic approach for managing refractory migraines, or migraines that do not respond to conventional treatments. It involves administering lignocaine, a local anesthetic with pain-modulating properties, intravenously under medical supervision. This medication stabilises nerve membranes by blocking sodium channels, which reduces the transmission of pain signals in the nervous system.

With anti-inflammatory and neuro-modulatory effects, lignocaine can potentially calm overactive neural pathways involved in chronic migraines. It may “reset” the hyperactive pain pathways in the brain, providing relief by decreasing central sensitization, a condition where the nervous system becomes overly responsive to stimuli.

This pain management treatment is administered in a hospital setting, and it typically lasts for several days, with the dose and duration adjusted based on your response and tolerance. Continuous monitoring of vital signs and potential side effects is required, as lignocaine can affect the heart and nervous system.

Patients with severe chronic or refractory migraines that have not improved with standard therapies like triptans, antiemetics, or preventive medications may benefit from lignocaine infusions. This option may also serve as a bridge therapy that enables you to regain control and enable other treatments to be more effective.

Potential side effects include drowsiness, dizziness, nausea, or mild tingling. Note that effects may be temporary, and repeated infusions may be needed..

How do Anti-Migraine Medications Alleviate Chronic Pain?

Anti-migraine medications can alleviate chronic pain through several mechanisms, depending on the specific type of medication used. Many of these medications target neurotransmitter systems, stabilise nerve activity, and modulate pain pathways.

Beta Blockers

Beta blockers like propranolol and metoprolol reduce heart rate and blood pressure by blocking the effects of adrenaline and stabilising the nervous system.

They can reduce the frequency of migraines, thereby alleviating the chronic pain associated with frequent migraine attacks. The calming effect on the nervous system can also help manage anxiety-related pain.

Antidepressants

Medications like amitriptyline/nortriptylline, which are primarily used as antidepressants, modulate neurotransmitter levels (serotonin and noradrenaline) and inhibit pain pathways.

These medications are effective in treating chronic pain conditions, such as fibromyalgia or neuropathic pain, due to their ability to increase pain tolerance and improve overall mood, which can reduce the perception of pain.

Antiepileptic Drugs

Medications like topiramate and gabapentin stabilise neuronal membranes and reduce excitability in the brain. They increase GABA activity and inhibit excitatory neurotransmitters like glutamate.

These drugs are effective for various types of chronic pain, including neuropathic pain and migraines. Their ability to stabilise nerve activity helps prevent the chronic pain associated with conditions like migraines and neuropathy.

Combination Therapies For Migraine Pain

Sometimes, a combination of different medications is used to maximise pain relief. For instance, a beta blocker combined with an antidepressant or an antiepileptic drug may provide synergistic effects. This approach can lead to improved management of chronic pain by addressing multiple pathways involved in migraine and chronic pain syndromes.

Why Would You Take Anti-Migraine Medications?

Anti-migraine medications are often prescribed for chronic pain due to their effectiveness in targeting specific pain pathways and mechanisms that are also relevant in various chronic pain conditions.

Migraines and Related Chronic Pain

Chronic migraines and other forms of chronic pain often share similar neurological pathways, including the involvement of neurotransmitters like serotonin and noradrenaline. By targeting these pathways, anti-migraine medications can effectively reduce pain.

Many anti-migraine medications, such as tricyclic antidepressants and antiepileptics, modulate pain signalling in the brain, making them effective for conditions like fibromyalgia, neuropathic pain, and tension-type headaches.

Preventive Benefits

Anti-migraine medications can help prevent the occurrence of migraines, which in turn reduces the overall burden of chronic pain for individuals who experience frequent attacks. This preventive approach can lead to improved quality of life and fewer pain episodes.

By reducing the frequency and severity of migraines, these medications can provide long-term relief from chronic pain associated with recurrent migraine attacks.

Improved Functionality and Quality of Life

Managing chronic migraine pain effectively can significantly enhance an individual’s ability to carry out daily activities, improve work performance, and foster better social interactions. Anti-migraine medications can contribute to these improvements.

• Mental Health Benefits: Chronic pain often coexists with anxiety and depression. Many anti-migraine medications, especially antidepressants, help improve mood and reduce anxiety, which can further alleviate the perception of pain.

Multimodal Pain Management

Anti-migraine medications can be part of a multimodal pain management approach, used alongside physical therapy, lifestyle modifications, and other pain relief strategies. This comprehensive approach can lead to more effective pain management.

Some anti-migraine medications can be used for various types of pain, including neuropathic pain and fibromyalgia, making them a versatile option for individuals with multiple pain conditions.

Overall, anti-migraine medications can contribute to a more holistic approach to pain management, addressing not just the pain itself but also the underlying neurological factors that contribute to chronic pain conditions.

Risks of Anti-Migraine Medications

Anti-migraine medications can be highly effective in preventing and managing migraine attacks, but like all medications, they come with potential risks and side effects.

Risks of Beta Blockers

Beta blockers can slow the heart rate, leading to bradycardia (an abnormally slow heart rate) in some patients.

Patients taking beta blockers may experience fatigue, dizziness, or lightheadedness, especially when standing up quickly.

Non-selective beta blockers can exacerbate asthma or other respiratory conditions by causing bronchoconstriction.

Risks of Antidepressants (Amitriptyline or Nortriptylline)

These medications can cause drowsiness and fatigue, which can affect daily activities.Some patients may experience weight gain due to increased appetite or metabolic changes. Amitriptyline can also affect heart rhythm and may not be suitable for patients with pre-existing heart conditions.They can also cause dry mouth, constipation and cognitive side effects, mood changes, nightmares and urinary retention.

Risks of Antiepileptic Drugs (Topiramate, Gabapentin)

Antiepileptic drugs may cause cognitive side effects, such as memory problems, difficulty concentrating, and drowsiness. Topiramate can lead to weight loss, while gabapentin may cause weight gain in some individuals. Patients may experience nausea, diarrhoea, or constipation with these medications. Topiramate may also affect mood adversely and is not suited in individuals with uncontrolled depression or anxiety disorder. Gabapentin rarely causes mood change and in some cases can cause lower limb cramps or swelling.

General Risks of Anti-Migraine Drugs

Many anti-migraine medications can interact with other medications, leading to increased side effects or reduced effectiveness.

Discontinuing certain medications abruptly may lead to withdrawal symptoms or the return of migraine attacks.

Some medications may not be suitable for individuals with specific health conditions, such as pregnancy, liver or kidney disease, or certain psychiatric disorders.

Monitoring, regular follow-ups, and individualised treatment plans can help mitigate these risks and ensure effective migraine management.

Finding a Persistent Pain Doctor Who Treats Migraine Pain Near You

If you are suffering from migraines and related chronic pain, then a regimen involving these medications may work for you.

To find a doctor near you who treats persistent or chronic migraine pain, ask your general practitioner for a referral to a pain management physician.

Also, you can research pain management clinics online or speak to family members, friends, or support groups (both online and in real life) for recommendations; those who have dealt with similar migraine issues or other problems may have valuable advice to offer.

Anti-migraine drugs can alleviate some types of migraine and related chronic pain, providing a higher quality of life for patients dealing with these conditions that have not responded well to other treatments.