Brain meds that allow for triptans too

August 24, 2023 7:24 AM

Migraine sufferer would like suggestions to present to my family doctor for new meds. The current combo ain't cutting it.

Basically, I'm on 15 mg Lexapro for my anxiety, and Cambia for migraines. The Cambia doesn't do jack, and I can't take triptans on Lexapro because of serotonin syndrome. (My doctor will not prescribe them because of this.) After an utterly debilitating episode on Sunday that caused me to cancel a weekend trip (thus costing me money because all that shit was non refundable), I have decided I'd like to figure out what I can take for the anxiety but what else I can have access to when I do have those disgusting migraine episodes where I cannot leave my bedroom, much less my house.

Current cycle of migraines is about every two months. I get no aura or any other warning. I still suck at learning my triggers (we figured out sugar was one, and alcohol was another but I am five years sober).

I am in Canada, and I cannot switch doctors because we are kinda short of those up here. So any replies that recommend finding a new doc will be hella ignored.

posted by Kitteh to Health & Fitness (13 answers total)

Just to consider the possibilities, are CGRP antagonists like Erenumab/Aimovig an option?
posted by zamboni at 7:43 AM on August 24, 2023 [1 favorite]

There are new CGRP inhibitors that were a godsend for me. I take a preventative injectable once a month, but there are also acute oral treatments using the same mechanism. It has reduced my migraine incidence and severity by at least 80%.
posted by graticule at 7:45 AM on August 24, 2023 [1 favorite]

Is your blood pressure a little bit high or on the high side of normal? My blood pressure was just a little bit high for two dr visits in a row and he put me on Lisinopril. After taking it for a month I realized the frequency and intensity of my migraines reduced very substantially. These days I get them very infrequently and can sometimes stop them with advil if i catch them early enough. There are still occasions where I have to use my maxalt but it is very rare. Also, my triggers went from being just about anything to almost exclusively the weather.
posted by jmsta at 7:47 AM on August 24, 2023 [1 favorite]

Best answer: I hear you, fellow Canadian migraine sufferer who cannot take triptans! Been dealing with this for 15+ years, so hopefully there's something here that can help.

Resources - I've recently discovered MigraineSociety.ca and MigraineCanada.org which are (as the title suggests) tailored for Canadians. I haven't gone though all the content yet, but there seems to be quite a bit.

Doctors: Getting a new GP is off the table, I completely understand. It probably wouldn't help anyway. What I would do is ask your GP for a referral to a neurologist or migraine specialist. It'll take months, so might as well get started now. If you were in BC, I've heard good things about the Headache Clinic at UBC; maybe Ontario has something similar?

For over the counter solutions: Advil/ibuprofen or naproxen. I've switched to naproxen primarily (you can also get a prescription for a stronger dosage) but do not mix it with any other NSAID (ie advil). YMMV.

Prescriptions: There's quite a few. Starting with preventatives (medications taken daily to prevent migraines), this list is a good resource, but gets really into the weeds with options. Of their "first line" suggestions I think I've tried them all. I won't recommend my particular combo, because everyone is going to be different and my situation is almost certainly different than yours. All I can do is suggest asking your doc.
For acute meds (these are the ones you take when having an attack, and the category Triptans falls into) there are fewer options, and for me this is where naproxen can help. I've also heard good things about the "newer" meds like Ubrelvy, but I haven't tried them yet myself, and this is definitely neurologist territory; your regular GP probably wont be prescribing these first.

Good luck... if it helps, know you are definitely not alone. If you're on FB, the Migraine Society mentioned above also runs a couple different support groups that aren't horrible.
posted by cgg at 8:18 AM on August 24, 2023 [1 favorite]

CGRP all the way. Botox if you can get it. Cannabis.
I have been doing the migraine rotation of meds for nearly 30 years. I take Nurtec as an acute medication. I also went old school beta-blocker (after a lot of trial and error bunch of things) and now have Inderal as a daily prophylactic. I do botox injections every 6 weeks-- I have found this very helpful. I also have a cannabis certification for medical cannabis-- is that something you can consider?
Also, my neurologist and I have talked about infusion if this regimen doesn't hold out. This might be an option as well for you.
posted by oflinkey at 8:38 AM on August 24, 2023

A couple options for anxiety instead of for migraines (IANYD, TINMA)

Buspirone is rated as lower risk interaction and risk of serotonin syndrome than lexapro, but not zero risk

Silexan is an OTC (Calm Aid) in the US with good clinical trials for generalized anxiety, unsure re availability in CA

Propranolol is not the best option for generalized anxiety but can help with situational/performance anxiety, also a preventive for migraines

Pregabalin also has good evidence for helping anxiety though not it’s main use
posted by loopsun at 9:37 AM on August 24, 2023

My patients usually have brain pathology that legitimately disrecommend triptans, so here's my path:
- Mg/B2/CoQ10 combo recommended waaaay down on that migrainesociety.ca list as a first 'go to' for my patients with undertreated migraine; You can get the individual meds or a combo supplement that might include Feverfew (which can aggravate hayfever.) It's a daily preventative.

- Some people get help with metoclopramide (anti-nausea) for acute attacks, others do not. It's commonly prescribed for diabetic stomach issues, so some non-neurologists may not be familiar with using it. This plus acetaminophen can work if taken rapidly on onset.

- Frankly, the next step for someone with only every 2 month headaches would be a newer abortive med, the anti-CGRPs ('Gepants'). This would be neurologist-only likely, and sometimes you need to prove you've 'failed' other trials (at least, in the US.)

Keep working on ID'ing your triggers - turns out one of mine is 'irregular sleep'. If you have one of the many migraine apps, use it. Also when it comes on, even just a little? Meds ASAP, no waiting it out.
posted by cobaltnine at 9:54 AM on August 24, 2023 [1 favorite]

The Reddit Migraine forum is amazing, definitely worth checking out the archives there.

Most relevant to your question, here is their mega-list of all the possible treatments you can try, in a handy spreadsheet, with worksheets you can download to use on your own or take to your doctor.
posted by EllaEm at 10:33 AM on August 24, 2023 [1 favorite]

I'm on a very high dose of Verapamil, and that has helped IMMENSELY. It's a blood pressure medication, so if you have low BP or low heart rate, it might not be an option. But after 35 years of migraines, it's the first medication that's dropped my bad days from 10-15/mo to 4-5 a year.
posted by headspace at 3:28 PM on August 24, 2023

It's gonna sound too good to be true but 400mg of magnesium daily has done wonders for my migraines. There is a decent amount of research backing up its efficacy, however. Might be worth trying.
posted by Jess the Mess at 6:45 PM on August 24, 2023

Botox injections are very much worth trying. As a long term sufferer after my second round, my 12-15 migraines per month went down by at least half, and the severity was much lower as well.
I also found one of my biggest triggers was being out in the sun without a hat and sunglasses. Why it took me forever realize that one, I don't understand, but I always have both with me now wherever I go. I also know I need to stay hydrated, eat at regular hours, get regular sleep, and I take 400mg of magnesium, Also 300mg CoEnzyme Q-10, 400 mg Riboflavin.
posted by mmf at 7:26 PM on August 24, 2023

I don't think Botox will be an option for you since your episodes are infrequent. A med I've found really helpful lately is an old one called Esgic. It's caffeine, acetaminophen, and maybe...phenobarbital? It's not prescribed much any more as far as I know and is very addictive. I am only allowed to take max 4 per month per my neuro.
Another thing I always have to remind myself is to take meds immediately upon headache symptoms. Too often I wonder if it'll abate on its own and then it doesn't and by the time I take my meds it's that much worse.
Last, you may want to look into cephaly. I've tried it in the past but often forget I have it.
posted by bookworm4125 at 2:01 AM on August 25, 2023

Neurologist and fellow migraneur here. This is not medical advice, but CGRP inhibitors are quite effective for lots of people. I subspecialize in a different field, but when I staff the resident clinic, I am always amazed at how much better people get with CGRP inhibitors. They are injectable, so a person has to be ok with that. (Needle is not visible, but it's still a bit painful, like a flu shot.)

Esgic (which I know under the US brand name Fioricet) contains butalbital, same class of med as phenobarbital (they are both barbiturates and will show up on a drug screen, if that matters). Lots of rebound headache when it wears off and the person needs more more more. 90% of my general neurology practice, when I had one, was trying to wean people off Fioricet which is like weaning off opiates but with even less support. (Incidentally, meds like Fioricet are why headache neurology gets a bad rap and no one wants to specialize in it, at least in the US.)
posted by basalganglia at 4:07 AM on August 25, 2023 [1 favorite]