So You Think You Have Tried Everything, Do You? Then Think Again. Part III

When everything in Tiers I and II have failed, we are halfway there.  Here are some of the things to try at this next level.

Abortive / Symptomatic-Pharmacological Treatment Tier III

Remaining Triptans

1)      Frovatriptan,

2)      Almotriptan,

3)      Zolmatriptan oral tablet


I’ve seen patients fail completely six out of seven triptans and then the seventh one works great. They are each different and worth trying. Frovatriptan is longer lasting than the others, Almotriptan has some of the lowest side effects, and zolmatriptan is in the middle of the road on both effectiveness and risk for side effects.



The only major negative about using these three triptans is that they are brand only at this juncture and the insurance companies don’t usually pay for them. That makes them very difficult to use.


Sumatriptan injection (Imitrex®) Pros:

Many people have tried oral or nasal sumatriptan and, if it didn’t work, they gave up on the medication.  However, the injectable form is far more effective and quicker acting and it can work when the pills fail.  It is also generic and usually covered well by insurance companies.



Sumatriptan comes in a variety of injectable forms, some are easy to use and some are not.  It is an injection and some people are needle phobic. Because it has such rapid onset, a “head rush” or other mild side effects are common.  For some people, this makes them too nervous to enjoy the benefits.

Dihydroergotamine injection (DHE 45®) Pros:

This is the gold standard for headache treatment and works almost 80% of the time.  It is derived from a natural source.  It is long-lasting, actually reverses the headache and does not cause rebound headaches.



Many patients do not like the idea of giving themselves injections. This medication’s price has increase significantly over the past decade and some insurance companies have stop paying for it. It does burn when injected. When patients self-inject, it can be complicated as it does not come in easy-to-use “EpiPen®” type of injectors but in tiny glass bottles (ampules) that have to be broken and the medication drawn up and then injected.



Prevention Non-pharmacological / Tier II

Supplements No additional ones to add at this level



OnabotulinumtoxinA (the generic name for Botox® ) has to be one of the most studied treatments for virtually all types of headaches.  However, the only type that showed significant improvement from onabotulinumtoxinA injections is Chronic Migraine. It often works when other things have failed.  It doesn’t involve taking a mediation that is absorbed in the gut and can have a lot of side effects.  It has also been widely used for 20 years and appears quite safe when used correctly.



The number one problem is that it is very expensive. One treatment costs about $1800-$2500 and the treatments need to be repeated every 90 days. The most common side effects are the small pain of getting 32-35 injections around the head and neck and, rarely, a droopy eye.


Facet Joint Blocks  

If the patient’s headaches seem to start from the neck or they have neck pain in addition to their headaches, it might be worth seeing an intervention pain clinic and having facet joint blocks and possible ablation.



If facet joint blocks or ablation works, it can make a lasting difference.



One of ten things the American Headache Society considered as treatments that are NOT helpful to headaches, is the overuse of facet joint blocks and ablations.  This issue didn’t make their final cut of five.  But it does raise concern that these treatments are invasive, can be permanent (in the case of ablations) and have limited proof of being helpful.



Prevention Pharmacological / Tier III

Pregabalin (Lyrica®) Pros:

Headache studies are pending, however, in my experience, it has been quite effective, even with patients who have failed other mediations.



Because it is branded, expensive and not yet approved for headache treatment, it is very hard to get it covered by insurance companies.  If the patient also has one of the disorders that it is approved for (fibromyalgia, seizures or neuropathic pain) it can be covered under that diagnosis.  Its side effects are drowsiness and sometimes weight gain.

methylergonovine maleate (Methergine®) Pros:

This is one of the most effective classes of medications for the prevention of migraine.  This class comes from a natural source (ergot fungus) and has relatively low side effects.  For many patients, this is the only medication that has ever worked to prevent their headaches and it is a godsend.



In the late ‘60s, Cleveland Clinic reported several patients who had been on Methysergide (Methergine’ cousin) for years developed scar tissue in their kidneys, lungs or on a heart valve.  This has not been observed with methylergonovine, however, we should assume that it could happen.


These drugs continue to be used by headache specialists because they are so effective, but they are only safe on a program where you stop them every six months for a month and do testing once a year to rule out the scar tissue formation.


The real risk of taking methylergonovine, if you follow the safety protocols mentioned above, is quite low.  However, the perceived risk causes more problems.  Some patients are simply scared of it, and that is understandable.  Other patients are warned, by pharmacists with good-intentions, that it is very dangerous and we, headache specialists who are prescribing it, are reckless. This creates distrust and confusion, making the use of this medication more complicated.  The final complication is the fact that there is so much concern about lawsuits that the companies that make it have threatened to stop.




Under this title of “exotics” are a long list of medications that can be tried and seem to work for subgroups of patients, but not the majority. At this tier, it is worth trying these things because the patient might be the one to respond.


Here is just a partial list of these medications;


a)      Timolol

b)      Clonidine

c)       Cyproheptadine

d)      Candesartan

e)      Lisinopril

f)       Acetazolamide

g)      Fluoxetine

h)      Lamotrigine

i)        Nabumetone



In my experience, these may work for a minority of patients. Sometimes they work well for select few.  The scientific evidence for supporting their usefulness is limited.  Some of these have particular groups that they work best for, such as acetazolamide might work for migraine with dizziness, cyproheptadine for children and lamotrigine with profound aura.



The fact that these do not work for most patients. Some, such as cardesartan, are not covered well for headache treatment.  Each have their own peculiar side effects.