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dihydroergotamine

“Older” Migraine Meds on Trial: What Works?

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Late last year a new study analyzed almost 4.7 million migraine attacks and the medications that patients took. According to those patients, which abortive medications actually worked?

The data was collected from patients’ responses on a smartphone app between 2014 and 2020 (which is why newer medications like gepants and ditans were not included in the study). Dosage was also not taken into consideration. Finally, the “baseline” was ibuprofun. In other words, which medications worked better than (or not as well as) ibuprofen?

However, as you can see, the sample size was huge. So which medications, according to patients, really fought back against an individual migraine attack?

It shouldn’t surprise too many that the migraine-targeting meds worked best:

  • Triptans (e.g. eletriptan, sumatriptan, zolmitriptan) were at the top of the list, working well 5x more often than ibuprofen.
  • Ergots (dihydroergotamine and ergotamine) were 3x more effective than ibuprofen
  • Anti-emetics (anti-nausea medications) were 2.5x more effective
  • Next came opioids, and NSAIDs (not including ibuprofen)

This is not to say that ibuprofen isn’t effective. It was still effective 42% of the time. And it roundly beat acetaminophen (paracetamol), which was effective 37% of the time.

But other similar NSAIDs other than ibuprofen may be worth trying – especially ketorolac, which came out as working 62% of the time, significantly more than its cousin ibuprofen.

Since triptans topped the list, which triptans tended to work the best? Well, it was the ones listed above, but not in that order:

  • eletriptan
  • zolmitriptan
  • sumatriptan

They were all considered effective over 70% of the time – and remember, triptans very much depend on the person, and also how they’re taken.

There’s no doubt that these “older” medications, even ibuprofen, are still helping a lot of people. Lists like this won’t necessarily tell you what will work for you. However, they do give you a place to start.

Your doctor will be able to take more of your personal medical history into consideration when recommending a medication. And there are also risks and side effects to consider, which also vary from person to person.

But if you’re a candidate for a triptan, one of the top three is probably going to be high on your doctor’s list. Tylenol, on the other hand, might be best left on the drugstore shelf, until you’ve tried some better options for migraine.

For the actual study abstract, you can go to Simultaneous Comparisons of 25 Acute Migraine Medications Based on 10 Million Users’ Self-Reported Records From a Smartphone Application.

For another more detailed analysis, check out Certain Migraine Medications May Be More Effective Than Ibuprofen.

New Approaches to “Aggressive” Migraine Treatment

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Migraine symptoms are sometimes “endured” for months or years without serious focus on treatment. Many people are being told that migraine is “normal” and that they just have to “put up with it” and “take an aspirin” (not that aspirin is always a bad idea).

Aggressive Migraine Treatment at the Hospital
Aggressive migraine treatment often requires hospitalization…

There are other patients who have tried many treatments, and are still, or now, experiencing several headaches a week, or almost constant migraine symptoms. And so “aggressive” treatments are finally tried.

One such aggressive treatment is used for children and teens as well as adults who haven’t responded to many of the most effective drug or even surgical treatments. It’s intravenous dihydroergotamine (DHE) therapy.

This is a serious, aggressive therapy because it generally involves hospitalization. Patients are given DHE every few hours (perhaps 3 times a day).

Results of this kind of treatment have been quite positive. Not only are many patients much better or even headache free at the end of the treatment, the improvement is often sustained for many months afterwards. (A couple of quick examples – see Repetitive intravenous dihydroergotamine as therapy for intractable migraine. and Inpatient treatment of status migraine with dihydroergotamine in children and adolescents.)

In spite of the positive results, one of the biggest drawbacks to this treatment is that full hospitalization is very expensive.

But trying to take the treatment to the next level, some specialists in Kansas City are using what they call the “Comprehensive Aggressive Migraine Protocol”, or CAMP. This is a 5 day treatment protocol for 11-18 year old patients. CAMP aims to make two major improvements:

  1. This is “outpatient” treatment, so full hospitalization is not required.
  2. Instead of full focus on DHE, the DHE treatment is combined with other treatments, such as massage therapy, relaxation training, and aromatherapy.

This type of treatment may not only save money, but also save on the extra stress of full hospitalization, as well as the possible stress of having the full focus on the intravenous DHE treatments. Also , it helps the patents take control of their condition by learning techniques that they can use at home in the months ahead. Finally, it brings a number of treatments together, which could mean better long-term success.

CAMP was the focus of a recent study, and here are the results

On average, headache intensity declined by 58% over 5 days of treatment (P<.01). Headache frequency decreased by a mean of 1.5 days per week (p=.01) through 3-month follow-up, with a 27% reduction in the proportion of patients reporting a continuous headache (p<.01). There also was an average reduction of 76% in school days missed per month (p<.01) and significant reductions in indices of healthcare utilization (healthcare provider calls and ED visits) (p<.01).

Enhancing outpatient infusion with interdisciplinary care to manage refractory pediatric migraine: Preliminary outcomes from “CAMP” (the Comprehensive Aggressive Migraine Protocol) (P3.10-016)

One statistic alone – the 76% decrease in missed school days – should get our attention. That’s pretty significant.

Sometimes migraine does require “aggressive” treatment. This study reminds us that there are times when we should consciously take time out of “normal life” to really focus on serious treatment, because the benefits for ourselves and those we love in the months and years ahead can be very significant.

Aggressive treatment may take many forms, and one way specialists can help is by giving options to migraine patients – protocols of well-researched and carefully planned treatments, that can break the cycle of migraine symptoms.

Learn more about Dr. Jennifer Bikel, the study’s lead author, here. Read more about DHE treatment in general here.

Changing Treatments in Emergency

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Treating migraine in the emergency room of a hospital is a challenge, and opinions and methods are changing rapidly. Narcotics were once common, but researchers began to discover that patients taking narcotics in emergency (instead of other treatments – more on that in a moment) actually tended to be in the hospital longer and come back more often. This isn’t to suggest that they were “drug seekers”, but simply that the narcotics were less effective than was once believed – and side effects were more common.

Changes in the emergency department
Photo credit: bidgee
As our knowledge of migraine treatment has expanded, many other treatments have become commonly available. More and more, treatments are being given such as – hydration with magnesium (intravenous), sumatriptan, NSAIDS (such as ketorolac or diclofenac), and dopamine antagonists such as metoclopramide (for nausea and other gastric problems).

And older medication, dihydroergotamine, has been persistently used as well.

A meta study published this month in the American Journal of Emergency Medicine highlighted some of these changed (see link at bottom of this article). Comparing how things were at the turn of the millennium, the study found:

  • Dopamine antagonists are now used 3-4 times more often
  • intravenous fluids used over 6x more often
  • Dexamethasone (a corticosteroid) used 22% more (this one is quite new – and it seems to help keep migraine from returning in the short term)
  • Ketorolac used 7-8x more often (also somewhat new in emergency)

Narcotics are only give 1/3 as often as they were. Not only that, “discharge prescriptions” are down to a third or less or what they were.

An obvious question is – are the new procedures helping? That may be a complex question, but the same study did find that return-to-emergency rates were also down, to a third of what they were back in 1999-2000.

That return rate may not be quite as great as it sounds – only 12% returned before, now only 4%. Still, a significant difference.

For more on emergency room procedures, see:

Yes, Children Get Cluster Headache Too

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Although cluster headache usually starts in your 20s or 30s, children can, and do, get cluster too. Usually the symptoms start after the age of 10, but children with cluster have been reported as young as 6 years old.

Cluster Headache in ChildrenThe fact that cluster headache is extremely rare in children is no comfort to children who get it and their families who are trying to help them. Although we’ve talked about cluster headache in children before, it’s time for an update.

As with adult cluster, more males are diagnosed than females. However, a surprising number of girls get cluster as well.

But one of the biggest challenges is diagnosis. A study in 2009 of eleven children found that, on average, their symptoms began at the age of 8.5, but they went two years without a proper diagnosis.

Sadly, headaches in children are often considered to be caused by “stress” or “attitude”. However, a specialist who know what questions to ask can get to the truth a lot faster.

Another challenge is that cluster headache is not usually constant. Attacks typically last from 15 minutes to three hours. But they also go into remission. Headaches may occur once or several times a day for a while, and then disappear for months or years.

Symptoms in children tend to be similar to those in adults. That would include agitation and restless movement, one sided pain, congestion, and facial flushing and sweating. (For more detail, see Cluster Headache Symptoms)

Treatments for cluster are also similar to treatments in adults, partly because precious little study has been done specifically for children. One study found that oxygen, methysergide, verapamil, zolmitriptan and dihydroergotamine were particularly helpful for children, but that paracetamol/acetaminophen, ibuprofen and codeine with paracetamol/acetaminophen were not particularly helpful.

For more information:

Status Migrainosus – when the attack doesn’t stop (graphic)

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Status Migrainosus

A person with migraine without aura
has a severe debilitating migraine attack
which lasts longer than 3 days.
Even after temporary relief from medication,
the symptoms remain.


Misdiagnosis is frequent. You may have…

Always see a doctor if symptoms change
or are worse than ever.

Your doctor may recommend:

A few more resources:

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The articles on Headache and Migraine News are © 2004-2024 J. Cottrill.
Every effort is made to ensure the accuracy of each article, and to point you to further sources of information. However, this site is for informational purposes only and should never replace a visit to your doctor.