Which abortive medication would you consider Dr. Robbins?
Most daily headache patients take 2 or 3 abortive medications. They may have something for milder daily headaches, a migraine medication, and an “escape” analgesic for the severe migraine. With Heather, we do not want to go down the road of overused daily analgesics, but most patients want and need something for the daily headaches as well as for the migraine. In Heather’s case, we need to emphasize that we do not want to constantly chase the headache all day, but rather use the preventive medications and non-medication techniques to decrease the severity.
For Heather’s migraines, my recommendation would be oral sumatriptan at 100 mg. If patients have never used a triptan before, I start with a low dose the first time – such as half of a tablet. The muscle pressure, tingling, and other side effects of the triptans frighten many patients, and so we need to start patients on a low initial dose. This go-slow strategy should improve compliance. With the triptans and other anti-migraine abortive medications, early intervention is crucial. There is an enormous difference in symptom response between using the triptan in the first 30 minutes of a migraine, and waiting an hour or more.
For Heather’s daily headaches, we discontinue the Excedrin and instead have her use naproxen along with limited amounts of caffeine. I try and limit caffeine intake to 150 mg or, at most, 200 mg a day. She was taking 250 mg just in her daily dose of 4 Excedrin, with more in coffee, teas, and colas. The idea with daily abortives is to limit caffeine, use the longer-acting NSAIDS such as naproxen, and avoid addicting medications.
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