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Ask the Pharmacist: Always Have a Back-Up Plan

Q. Recently I needed treatment in the emergency room (ER) due to a really bad migraine attack. I only have one drug to use at home when an attack strikes and someone at the hospital said that I need two different drugs to use at home. Is this true?

A. How unfortunate to spend your time on an unplanned and probably preventable trip to the ER. At least the hospital personnel gave you some good advice. All migraine patients should have at least two acute medications at their disposal, one to use as their first-line treatment during an attack and one to use as a backup in those instances when the first drug does not provide relief. Even having a third drug option (a backup for the backup) is a wise decision for some patients. Ideally, patients should not only have more than one drug, but also more than one drug formulation.

Injections, nasal sprays, and suppositories typically provide quicker relief than oral tablets and bypass the stomach as well, which is important for patients suffering from nausea and vomiting. As a general rule, when you use an injection, nasal spray, or suppository, you should wait at least one hour, and preferably two hours, before taking any more medication. When you take a drug by mouth, you should wait at least two hours, and preferably longer, before taking any more medication. This waiting period allows the drug an opportunity to be absorbed by your body and then to exert migraine-relieving effects. After the waiting period, patients still suffering from an attack have the option to re-dose their first-line drug or to use the backup drug. Patients with multiple treatment options report feeling empowered to adequately treat their attacks, helping them avoid expensive and time-consuming ER visits, not to mention the migraine attack pain.

Avoiding Medications that Exacerbate Hypertension

Q. Is there a medication that can be safely used to relieve the symptoms of a migraine when hypertension is also a factor?

Q. What are the problems in taking Zomig® (zolmitriptan) over the age of 65?

A. Both of these questions are related since hypertension is common in people over the age of 65. First, let’s talk about some medications to be avoided or used cautiously in seniors or in individuals with high blood pressure. These drugs include triptans (Imitrex®, Maxalt®, Amerge®, Axert®, Relpax®, Frova®, and Zomig), ergotamines (Cafergot®, Bellergal®), and ihydroergotamines (DHE®, Migranal®). Because these medications can possibly increase blood pressure, all have warnings discouraging their use in people with risk factors such as hypertension or advanced age. Sudden changes in blood pressure elevate the potential for a heart attack or stroke, which are obviously conditions we want to avoid. Medications that can be safely prescribed include anti-inflammatories, steroids, antiseizure drugs, muscle relaxants, and narcotic agents. Thus, your healthcare provider can select from literally a dozen different drugs. Lastly, a final word of caution. Many individuals over age 65 or with hypertension often have other illnesses, such as diabetes, kidney problems, or heart conditions. In these situations, some of the medications I just mentioned should be avoided as well. The bottom line is that patients need to ensure that their healthcare providers are aware of all their illnesses, not only headache, since the presence of other diseases may limit which medications can be used.

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