Headache Medications

Headache pain may need to be managed with medications. Medications used to treat headache pain can be grouped into three different types:

• Symptomatic relief
• Abortive therapy
• Preventive therapy

Each type of medication is most effective when used in combination with other recommendations, such as dietary modifications, lifestyle changes (at least 7-8 hours of sleep and adequate hydration [6-8 glasses of water/day], exercise and relaxation therapy).

Symptomatic relief

This group of medications is given for the relief of symptoms associated with headache. This includes the pain associated with headaches or nausea and vomiting associated with migraine headaches. Many of the medications are available over-the-counter (without a prescription). Other medications require a prescription from your doctor. When taking these medications, avoid caffeine-containing foods and beverages and medications. Medications containing barbiturates (butalbital) or narcotics (codeine) should be avoided if possible. The use of aspirin should be avoided in children. Many of the medications listed for symptomatic relief are not recommended for use in young children (see end of document for discussion of ˜off-label' use.)

Over-the-counter medications for symptomatic relief non-steroidal anti-inflammatories

Generic Name	Brand Name	Symptoms Relieved	Precautions and Possible Side Effects
aspirin*	Bayer® Bufferin® Ecotrin®	Relief of fever and pain	Do not use in children under 14 years of age due to the potential for Reye's syndromeSide effects may include: heartburn, gastrointestinal (GI) bleeding, bronchospasm or constriction that causes narrowing of the airways, anaphylaxis and peptic ulcer.
acetaminophen, paracetamol	Tylenol® Panadol	Relief of fever and pain	Few side effects, if taken as directed, although they may include changes in blood counts and liver function
ibuprofen (NSAID)**	Advil® Motrin IB® Nuprin® Brufen	Relief of fever and pain, and inflammation	Side effects may include GI upset, GI bleeding, nausea, vomiting, rash and changes in liver function
naproxensodium (NSAID)**	Aleve® Proxen	Headache pain relief	Side effects may include GI upset, GI bleeding, nausea, vomiting, rash and changes in liver function

*Not recommended in pediatric patients

**Nonsteroidal inflammatory drugs

Prescription medications for symptomatic relief

Generic Name	Brand Name	Symptoms Relieved	Precautions and Possible Side Effects
Antiemetics promethazine HCI (available in tablet, syrup, injection or suppository forms)	Phenergan®	Nausea, vomiting	Confusion, drowsiness, dizziness, GI upset, excitability, nightmares, uncontrollable muscle movements, and lip-smacking or chewing movements
chlorpromazine (available in suppository form)	Thorazine®	Nausea, vomiting	Confusion, drowsiness, dizziness, GI upset, excitability, nightmares, uncontrollable muscle movements, and lip-smacking or chewing movements
prochlorperazine (available in suppository form)	Compazine® Stemetil	Nausea, vomiting	Confusion, drowsiness, dizziness, GI upset, excitability, nightmares, uncontrollable muscle movements, and lip-smacking or chewing
trimethobenzamide HCI (available in capsule injection, syrup, or suppository form)	Tigran®	Nausea, vomiting	Hypotension, blurred vision, drowsiness, dizziness, disorientation, uncontrollable muscle movements, and lip-smacking or chewing
metoclopramide HCI (available in syrup, tablet, or injection form)	Reglan® Primperan	Nausea, vomiting	Uncontrollable muscle movements, lip smacking or chewing movements, sensitivity to sunlight, aching of lower legs, diarrhea
ondansetron HCI (available in solution, tablets/ disintegrating tablets, injection)	Zofran	Nausea, vomiting	Diarrhea, dizziness, headache, constipation, malaise/fatigue, fever
Antihistamines cyproheptadine HCI (available in syrup or tablet form)	Periactin®	May induce sleep, may shorten migraine attack	Weight gain, drowsiness (also used as preventive therapy)
diphenhydramine HCI (available in tablets, liquids, liquid-gels)	Benadryl® (over-the-counter)	Nausea, vomiting	Sleepiness, dizziness, disturbed coordination, and behavioral changes

NOTE: For people using symptomatic relief more than twice a week, daily preventive therapy may be considered by your doctor. In addition, appropriate non-medicinal therapy, such as exercise, biofeedback, adequate sleep (at least 8 hours/night), adequate hydration (6 to 8 glasses of water/day), and diet can be used to decrease the frequency of headache attacks, eliminating the need for frequent pain medicines.

Abortive therapy

These medications are used early in a migraine headache to stop the process that causes the headache pain. In this way, they help minimize the symptoms of headache, such as nausea/vomiting and sound and light sensitivity. These medications are most effective if used at the first sign of a migraine. Some medications should not be used during a migraine aura; please follow the instructions of your doctor.

When headaches”and especially migraine headaches last longer than 24 hours and other medications have been unsuccessful in managing the attacks, medication administered in an infusion suite can be considered. An infusion suite is a designated set of rooms at a hospital or clinic that are monitored by a nurse and where intravenous drugs are administered. The intravenous drugs are usually able to end the migraine attack. Patients' length of stay at the infusion suite can range from several hours to all day.

Use of abortive therapies has not been approved for children (see end of document for discussion of ˜off-label' use).

Medications for abortive therapy

Generic Name	Brand Name	Possible Side Effects
Ergotdihydroergotamine mesylate	DHE-45® Injection Migranal® intranasal	Nausea, numbness of fingers and toes
TriptansSumatriptan succinate* zolmitriptan* rizatriptan* naratriptan HCI almotriptan malate*$ frovatriptan succinate eletriptan hydrobromide*	Imigran® injection oral or intranasal Zomig®, oral or Intranasal Maxalt® oral Naramig® oral Axert® oral Frova® oral Relpax ®oral	Side effects for all the Triptans are similar This class of drugs is well tolerated, but side effects may include: Nausea, headache, sleepiness, dry mouth, dizziness. fatigue, headache, hot/cold sensations, chest pain, flushing, sense of tightness around chest and or throat, and numbness

*short-acting = long-acting $ = FDA approved for teens ages 12 to 18

Overmedicating and rebound headache

People who are prone to having headaches may develop a pattern of daily or almost-daily headaches. In some people, migraine-type headache attacks may become so frequent that they finally blend together with no clear-cut beginning or end. In both of these cases, the development of more severe or frequent headaches may actually be caused from taking headache relief medications too frequently. Daily or almost daily use of over-the-counter medications such as aspirin, acetaminophen, ibuprofen, narcotics, barbiturates and caffeine-containing medications; or prescription medications such as the triptans, appears to interfere with the brain centers that regulate the flow of pain messages to the nervous system and may make your headache worse. In addition, overmedicating interferes with the effectiveness of prescribed preventive medications.

Rebound headaches may result from taking prescription or nonprescription pain relievers more than two days a week. If prescription or nonprescription abortives are overused, the headaches may rebound as the last dose wears off, leading you to take more and more medication and actually aggravate the pain. When the medications are no longer taken, headache pain will likely improve over a period of 6 to 12 weeks.

Preventive therapy

These medications are taken daily to prevent headaches. Some of these medications are used for other medical conditions and were accidentally discovered to help headache. While none of these medications cures headache, preventive medications may reduce the frequency, duration and severity of headache attacks.

The medications listed include both over-the-counter and prescription drugs. These drugs are not habit-forming, but any medication can cause unwanted side effects. Your doctor will work with you to carefully regulate the dosage so that side effects are minimized and headache relief is maximized.

To be effective, all preventive medications must be taken one or more times every day. It may be necessary to change the medications and modify their dosages in order to discover which medication or combination of medications, at which dosages, work best to reduce the frequency and severity of your headache pain.

While these medications are being used, carefully recording your headache frequency and severity on a daily basis will help your doctor judge how the medications are working. Most of these medications require days to weeks of daily use before they become fully effective in preventing headaches. A trial of about 8 weeks is recommended before the effectiveness of a medication can be judged by your doctor.

Once good headache control has been achieved and maintained for 6 months or a year, it may be possible to taper and stop these medications. In other cases, it may be necessary to take the medications for a longer period of time.

Preventive therapies have not been approved for use in children. (see end of document for discussion of ˜off label' use).

Headache "checklist of management suggestions"

• Educate yourself and your family. Read about your type of headache and its treatment.
• Maintain a headache diary.
• Ask your doctor for written instructions about what to do when you have a headache.
• Limit your use of over-the-counter and prescription abortive medications to two days per week. Excessive use can actually increases headaches.
• Follow a regular schedule:
  1. Don't skip meals, especially breakfast
  2. Get eight hours of sleep nightly
  3. Exercise 30 minutes/day
  4. Drink 6-8 glasses of water/day
  5. Learn to identify and avoid headache triggers. Common triggers include caffeinated foods and beverages (teas, chocolate, colas, coffee), nitrates (luncheon meats, sausage/hot dogs, pepperoni) tyramine (aged cheeses, pizza) Doritos® Ramen® noodles, other junk foods, and Asian foods containing MSG

• Daily school attendance IS A MUST.
• Initiate non-drug measures at the earliest onset of your headache.
  1. Seek rest in a cool, dark, quiet comfortable location
  2. Use relaxation strategies and other methods to reduce stress
  3. Apply a cold compress
• Don't wait! Take the maximum allowable dosage of recommended medications(s) at the first sign of a severe headache.
• Take prescribed medications regularly, as directed, and maintain regular follow-up visits.
• Call your doctor when problems arise.

Medications for preventive therapy

Generic Name	Brand Name	Possible Major Side Effects	Instructions When Used for Headaches
Tricyclic Antidepressants amitriptyline HCI	Elavil® Tryptozol	Fatigue, dry mouth, weight gain, and constipation	Frequently started at low dosages and slowly increased to a therapeutic level taken nightly, EKG optional
Antihistamines cyproheptadine HCI (available in syrup or tablet form)	Periactin®	May induce sleep or may shorten migraine attack, weight gain, drowsiness	Usually started at low dosages and slowly increased; often taken at bedtime
Selective Serotonin Receptor Inhibitors (SSRI)* fluoxetine HCI	Prozac®	Nausea, dry mouth, increased appetite, agitation	Usually started at low dosages and slowly increased; usually taken in the a.m.
Beta Blockers atenolol Propranolol HCI	Tenormin® Inderal®	Fatigue, depression, weight gain, faintness and diarrhea, memory disturbance, decreased performance in athletes	Depending on the form may be one to three times a day
Calcium Channel Blockers verapamil flunarizine	Calan® Isoptin® Sibelium®	Constipation, dizziness; hair loss	Frequently started at low dosages and slowly increased. Taken twice a day. Usually, the first dose is in the a.m.
Anticonvulsants valproic acid	Depakote®	Nausea, drowsiness, weight gain, tremors, and rare liver failure; may cause birth defects	Frequently started at low dosages and slowly increased. Periodic blood tests required.
topiramate	Topamax®	Rare: glaucoma, kidney stone at higher doses (>150 mg): weight loss, word- finding difficulties	Usually started at low dosages and slowly increased; may be taken two to three times/daily
gabapentin	Neurontin®	Generally well tolerated	Usually started at low dosages and slowly increased, maybe taken two to three times/daily

*Other SSRIs include citalopram (Celexa®), escitalopram (Lexapro®), fluvoxamine (Luvox®), paroxetine (Paxil®), sertraline (Zoloft®)

Important note about 'off-label' prescribing

Many of the medications listed in this handout have not been approved by the Food and Drug Administration (FDA) for use in children and adolescents with headaches. When a doctor chooses to prescribe a drug for a medical condition or for a certain patient type (eg, children) for which it has not received FDA approval, this practice is called ˜off-label' prescribing. This is a common practice in the field of medicine. It is one of the ways by which new and important uses are found for already approved drugs. Many times, positive findings lead to formal clinical trials of the drug for new conditions other than what the drug was first approved for.

Many of the drugs prescribed to help prevent head pain disorders are prescribed in this off-label fashion. Please check with your doctor regarding other medications not mentioned in this handout or if you have any concerns or questions.

Other notes

Pain medications that are least likely to be habit-forming should be tried first. In general, narcotic analgesics are not used in children and adolescents or adults. In all but the most severe headaches, the lowest strength dose should be tried first. Caution should always be used when taking stronger medications, because the more frequently the medication is taken, the greater the possibility that they could become harmful and less effective.

Guidelines for use of over-the-counter (OTC) pain relievers

Nonprescription pain relievers have been demonstrated to be safe when used as directed. In addition, keep the following precautions in mind:

• Know the active ingredients in each product. Be sure to read the entire label.
• Do not exceed the recommended dosage for age on the package”including for a single dose, for total daily dosage, and total weekly, dosage.
• Carefully consider how you use pain relievers and all medications; it is easy to over-medicate.
• Check with your doctor before taking products containing aspirin, ibuprofen or naproxen sodium if:
  1. You or your child has a bleeding disorder
  2. You or your child has asthma
  3. You or your child has recently had surgery or dental surgery or are about to have surgery
  4. You or your child has ulcers, kidney or liver disorders
  5. You or your child take other nonsteroidal anti-inflammatory medications

• Check with your doctor before taking acetaminophen-containing products if you or your child has kidney or liver problems.
• Children should not use over-the-counter medications that contain aspirin and/or caffeine.
• Children and teenagers should not be given aspirin, as aspirin has been associated with a rare but serious liver and brain disorder called Reye's syndrome.
• Avoid combination medications containing caffeine, barbiturates and narcotics.