Migraine remains a poorly understood condition that is frequently undertreated. Nearly half of all migraine sufferers are never diagnosed. Migraine affects nearly 1 in 4 U.S. households and the majority of migraine sufferers do not seek medical care for their pain. Even with the correct diagnosis, treating migraine can be very challenging. Combinations of various medications and other modalities are often the most effective therapy.

 

Researchers previously believed that dilation and constriction of blood vessels in the head were the primary source of migraine pain, and this was the focus of early medical therapy. Researchers now believe that migraine is a disorder involving nerve pathways and neurotransmitters.

Estrogen adversely influences the brain receptors that play a role in migraine development. About half of affected women have more than one attack each month, and a quarter experience 4 or more severe attacks per month. More severe and more frequent attacks often result from fluctuations in estrogen levels. 10-14% of American women get menstrual migraine. The vast majority of these women also have migraine at other times of the month. Menstrual migraine is an attack that occurs up to 2 days before and up to 3 days after menstrual onset. It is usually more severe and harder to control than other types of migraine.

Migraine triggers include alteration of sleep-wake cycle; missing or delaying a meal; medications that cause vasodilation; medication overuse (which contributes to the progression from episodic migraine to chronic migraine); bright lights, sunlight, fluorescent lights, TV and movie viewing; certain foods; and excessive noise. Stress and/or underlying depression are important trigger factors that can be diagnosed and treated adequately.

If patients have frequent migraine attacks, that do not respond consistently to migraine specific acute treatments, or if the migraine-specific medications are ineffective or contraindicated because of other medical problems, then preventive medications should be taken to reduce migraine frequency and improve response to acute therapy.

Management of migraine involves elimination of triggers, prophylactic therapy, and pharmacologic or complementary therapy when a migraine occurs. Therapy should begin at the first sign or symptom of a migraine.

For optimal therapy, the following factors must be considered:

• Severity of the migraine
• Side effects
• Efficacy
• Most appropriate route of administration (For example, oral meds would not be best for someone with symptoms of nausea and vomiting; sublingual and nasal preparations have a faster onset than oral medications.)

We can compound medications in the most appropriate dosage form for each patient.

The goal of acute therapy is to abort or reduce the pain and other symptoms associated with the migraine while minimizing adverse drug effects and ultimately restoring the patient's ability to function normally. For the acute management of migraine without aura, a double-blind, placebo-controlled trial demonstrated that in 83% of patients, a single dose of sublingual piroxicam 40 mg

Other examples of compounded medications include:

• Metoclopramide Nasal Spray or Suppositories
• Prochlorperazine 5 mg/0.1 ml Nasal Solution Spray, Buffered and Preserved
• Ergotamine, Caffeine, and Metoclopramide Suppositories
• Ergotamine Tartrate 2 mg. Sublingual Tablets
• Caffeine 25 mg/gram, Meloxicam 7.5 mg/gram, Promethazine 12.5 mg/gram Transdermal Gel
• Discontinued medications such as caffeine and ergotamine tablets (previously Cafergot®)

Case Report

Recurrent Migraine Pain Treated with Ketoprofen/Riboflavin/Caffeine Capsules and Progesterone

A 40 year old woman with history of hysterectomy at age 28 and recurrent migraines refractory to treatment with multiple triptans and ergotamine/caffeine suppositories was prescribed a compounded therapy of ketoprofen 12.5mg/riboflavin 100 mg/caffeine citrate 65mg capsules, with directions to take 2 capsules at onset of migraine then two capsules every 4 hours as needed. After 3 weeks, she reported that on four occasions, her migraine was relieved with only the onset dose, and on one other occasion, she required a follow-up dose. She then added progesterone cream (applied twice daily) and three months later reported that she had only two migraines in the three month period, and both were relieved with the Ketoprofen/Riboflavin/Caffeine Capsules.
International Journal of Pharmaceutical Compounding. May/June 2007; 11(3):200

Migraine is associated with a wide-spread metabolic abnormality of mitochondrial oxidative metabolism, leading to the use of riboflavin and coenzyme Q10 as prophylactic therapy for migraine. Riboflavin has the potential of increasing mitochondrial energy efficiency, and riboflavin 400 mg dailywas found to be effective for migraine prophylaxis, with decreased attack frequency, fewer headache days, and reduced severity of migraine. Riboflavin 400 mg can be compounded in an extended-release dosage form.

Genetic elevation of homocysteine levels in some patients with migraine with aura led to a therapeutic trial of cyanocobalamin, folate, and pyridoxine which resulted in lower homocysteine levels and improvement of migraines with minimal side effects.

Ask us for more information about therapies for migraine headaches. Our compounding pharmacy also has many unique delivery systems that can enhance patient compliance. Please call us with your questions - and send us your medication problems!

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