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Clinician’s Corner: What NOT to use for Migraine Headache Relief

Ergotamine preparations

Discussion of ergot alkaloids has a rich history that dates to known cases in the Middle Ages, that caused gangrene and hallucinations.  The Salem witch trials were believed to be due to ergotism.

It has been postulated that the 10th plague of the Egyptians was also due to wheat being infected by the ergot fungi (Claviceps purpurea) which caused ergotism, and then death of the first-born Egyptians.  Fortunately we have much better therapies today, and the ergots are seldom used.

Mechanism: in the cranial arteries, it promotes constriction and decreases pulsation.

Adverse effects: may cause nausea and vomiting in 10% of patients.  Weakness in legs, myalgia, numbness & tingling. May also cause angina-like pain.

Ergotism: Symptoms include hallucinations, severe gastrointestinal upset, abortions, dry gangrene, and a painful burning sensation in the limbs and extremities commonly known as St. Anthony’s Fire.  Ergotism was commonly seen in the Middle Ages as a fungal infestation of grains, especially rye grains.

Contraindications: heart disease, previous heart attack, uncontrolled blood pressure, other heart disease and pregnancy.

To reduce angina: do not give if risk factors: obesity, diabetes, high cholesterol, smokers, men over 40, post-menopausal women.

Drug therapy:

Ergotamine + caffeine

Cafergot®:  tablets: 1mg ergot amine + 100mg caffeine. Was an old product seldom used today.

Dihydroergotamine: seldom used today

Migranal® nasal spray 4mg/ml.

D.H.E. ® injection

The headache specialist says

  • Ergotamines are “hopelessly outdated”.
  • All ergots are pharmacologically nonselective for blood vessels and cause lots of side effects.
  • Narrow window of opportunity
  • Enhances Nausea
  • Modest efficacy
  • Cause cardiovascular effects.

OPIOIDS : GENERAL PRINCIPLES

As we are all aware opioids have a lot of side effects, and worst of all addiction potential.  They are no longer considered appropriate for the management of migraine headache.

Side effects for opioids:

Lightheadedness, dizziness, drowsiness, shortness of breath, nausea, vomiting, CONSTIPATION

Contraindications for opioids:

Alcoholics, heart failure, patients with opioid abuse potential

Patient information for opioids:

  • Watch for drowsiness, caution driving. Avoid alcohol
  • Caution abuse potential, using and storage.
  • Do NOT adjust dose without consulting prescriber.
  • Caution use in pregnancy

REMEMBER: Patients treated with opioids as first-line therapy are significantly more likely to return to the emergency department with a headache within seven days of the original visit

The headache specialist said:

Use of opioids for migraine treatment:

  • Pro-inflammatory! (migraine is an inflammatory disorder)
  • Vasodilator
  • Increases nausea and vomiting
  • Sedating
  • Drug seeking behavior

Discussion of ergot alkaloids has a rich history that dates to known cases in the Middle Ages, that caused gangrene and hallucinations.  The Salem witch trials were believed to be due to ergotism.

It has been postulated that the 10th plague of the Egyptians was also due to wheat being infected by the ergot fungi (Claviceps purpurea) which caused ergotism, and then death of the first-born Egyptians.  Yes, history is fun, but there is so much to learn about treatment of disease states with pharmacotherapies that are actually used

Got a headache… or a question… Go Ahead and ask your Thompson Pharmacist for direction.  At Thompson Pharmacy… it’s ALL for YOU!