MIGRAINES AND TRIPTANS [ back to What's New ]
Migraine is a common sequelae of closed head trauma, which may cause headache and disability longer than cognitive disruption, irritability and other symptoms associated with TBI. Bringing migraine under control through prophylactic medication (to prevent onset) and abortive medication (to stop headache already in progress) is essential. Biofeedback (for self-regulation of stress), nerve block injections to trigger points at the base of the head, neck or trapezius, and avoidance of known migraine triggers may help, but does not substitute for medication.  Today the family of 5-HT receptor agonists known as the triptans are among the best known and most effective migraine drugs of the abortive type. Anti-convulsant medications like Depakote are effective in preventing headache. SSRI medications like Sertraline are highly effective in reducing depression, but when tested as migraine preventers in persons with depression and migraine, they have shown little promise. The best known of the triptans is sumatriptan (imitrex), which has worked well for my clients. Newer triptans have come out with new benefits. Amerge (naratriptan) can tackle even stronger migraine headaches than Imitrex. Maxalt (rizatriptan) is extremely well tolerated by migraine sufferers who experience nausea, because it comes in a tiny pill which dissolves quickly under the tongue and does not require a glass of water. A recent study showed that Maxalt is absorbed twice as fast into the bloodstream than aspirin, tylenol or non-steroidal anti-inflammatories like Ibuprofen. Migraine appears to slow digestion in the GI tract, but this slowing is bypassed by Maxalt. How do these medications work?   A new study in Journal of Neuroscience (5/1/99) shows how Imitrex works. The trigeminal nerve is a large cranial nerve in the head with 3 sensory branches about the eyes, cheek and jaw. Once the trigger (e.g. bright light) activates trigeminal ganglion neurons, they release CGRP (calcitonin gene-related peptide). This sets off rapid expansion (dilatation) of the diameter of blood vessels in the head, degeneration of mast cells and release of inflammatory substances such as substance P and neurokinin. These substances signal the trigeminal to release more CGRP in a feedback loop which can make a head squeezing migraine last up to 72 hours. The study showed that Imitrex causes the trigeminal ganglion neurons to hold extra calcium ions over a prolonged period of time, which blocks potassium-stimulated CGRP release. Thus Imitrex interferes with the increased phosphatase activity involved in the inflammation process. Administration of Imitrex rapidly reduces the level of CGRP back to normal (basal) levels with shrinkage of blood vessel diameter and reduction in headache severity and duration.