Take at first sign of Migraine

If you are among those lucky enough to be able to use drugs in the triptan class, Migraine abortives, you've seen this advice "Take at first sign of Migraine."  Most of us find them quite effective when we follow this advice.  But like many things in real life, following the advice isn't easy.

Triptans were the first, and are so far the only, class of drugs specifically designed to abort a Migraine attack.  When they were first introduced in the 1990's, they revolutionized the treatment of Migraines.  Rather than simply treating pain, or reducing the inflamation of blood vessels, they work directly to end the neurological process which is Migraine.

As described by Dr. Gary L'Europa in his excellent article last June in the Providence (RI) Journal, Stop Limiting Migraine Medicine , the migraine process includes these phases:

     "Prodrome consists of fatigue, neck pain, hunger, thirst, and other physical symptoms that occur up to 24 hours before the headache.

     "Aura occurs up to 60 minutes before the headache and produces a sensation of seeing sparkling lights or feeling numbness or tingling in the face and hand.

     "Headache, lasting as long as 72 hours, consists of severe throbbing pain similar to that associated with meningitis. This pain is often associated with nausea, vomiting, light and sound sensitivity.

     "Postdrome consists of fatigue, neck pain and lethargy that lasts 24 to 48 hours after the headache."

So what's the first sign of Migraine?  Most migraineurs report that triptans are not particularly effective in the prodrome phase; they wait to take them at the first sign of headache.  I can attest to the fact that my triptans are most effective if taken at the very first sign of head pain.  I haven't tried them in prodrome, since fatigue, neck pain, hunger, thirst (and irritability) can have other causes.  Also because I am afraid to waste one of my precious triptans.  Which brings us to my main point.

Triptans tend to be very expensive.  Imitrex, which I take, retails at around $20 to $30 per pill.  It often takes two doses to end a Migraine attack.  Given the cost of triptans, many insurance companies began in 2007 to set lower limits on the number of doses per month they would cover.  My coverage went from 9 per month to 4.  This was based on some math they had done on what the "average" migraineur needed.  I guess I can take pride in being, once again, "above average!"  I have 4 - 5 migraine attacks per month.  Migraine researchers estimate that 46% of migraineurs have more than 3 attacks per month.  Do they limit the doses of insulin a diabetic can have to the amount an "average" diabetic would need?  (Maybe they do... someone fill me in... either way, it's a scandal!)  Seems to me the reason our doctors prescribe for us, not our insurance companies, is because they treat the actual patient, not the average patient!

My insurance company politely suggests I look at having another triptan prescribed for me, as Imitrex is one of the most expensive.  I'd be happy to, but becasue of my multiple drug allergies, the neurologist I saw recently wasn't willing to prescribe a different one at this point. 

As Teri Robert pointed out in her article Doctor speaks out about insurance limiting triptan Migraine medications,

     "Limiting triptans is beyond absurd. It's counter productive, inane, and cruel. Many Migraineurs, when faced with a Migraine and no triptans, end up in the emergency room. Ever pay an emergency room bill? The cost of a reasonable month's supply of triptans costs far less than a single ER visit. Duh! Maybe part of the problem is that many insurance plans have two parts -- medical care and prescription coverage. The people managing the prescription coverage don't care about ER payments because that's a different budget."

After many calls, 4 months, over $350 out of my pocket for medication (and several seemingly stress triggered Migraine attacks following calls to the insurance company,) they have now told me they will cover 9 pills per 23 days.  This comes out to almost 12 doses per month.  Which ought to be enough for my average month, but...

Can I take the Imitrex at the first sign of Migraine?  Certainly not.  I have moments, or sometimes hours, of mild migraine pain up to 8 times per month.  That's on top of my 4 - 5 "full blown" migraines.  This may be the sign of a transforming migraine pattern.  I have an appointment with a bona fide migraine specialist in early June - we'll have to talk on this blog about the lack of qualified headache specialists another time.  For now, my attitude seems to be that the pain isn't bad - many of you have it worse - so I save the Imitrex for when I feel a "real one" coming on.

Is this a good strategy?  Probably not.  My other alternative, I suppose is to pay out of pocket for additional Imitrex (at $26 per pill at my local pharmacy.)  I do get what samples my doctor can spare me when I see him.  But I have to say, when it comes to aborting Migraine, most of us are between a rock and a hard place.

- Megan Oltman

It's a paradox wrapped in an enigma!

                                                              Signs of Spring photo courtesy of Just-Us-3 

                                                              Hammer photo courtesy of Darren Hester

Comments

[MaxJerz]

I talked to my HA specialist about this at my first visit, and intend to talk to her about it again because I still don't feel like I have a satisfactory answer.

As you probably remember I have daily migraines (probably transformed migraine, but I don't have the official diagnosis at this time). And by daily that means 24/7 pain. So really, there is no "first sign" of pain for me. And I certainly can't take triptans every day or I'll end up in MOH pretty fast. Even before my daily migraines I had CDH - which some experts believe is a form of migraine. (And sometimes I do wonder, because of the nearly constant vertigo and nausea I also have - nothing ever fits neatly into one diagnosis.)

When I last saw my neuro in December, he said to take my triptans at the first sign of pain, and that meant if I woke up with it to take it then, but no more than 2-3 times per week. I tried this a few times but without much success. When I saw my HA specialist a few weeks later she told me the triptans probably would not be able to get me below my "base" level of pain, only treat the higher-level migraines. And in my experience, she has been correct.

The trouble for me has been that some weeks, I hit a 5-6 pain level every single day. I can only take triptans 2 consecutive days or I'll end up in rebound (3 days a week is ok, just not 3 consecutive). It is *so* hard to judge which days I should take a triptan and which I shouldn't.

I am very fortunate that one dose of Imitrex + ibuprofen, or Frova + ibuprofen, is usually enough to knock my pain down below a 5. But I guess the tradeoff is that I'm never pain-free. :-/ And I still have no rescue plan to speak of!

So much about this disease is complicated - it just makes it all worse.

[MaxJerz]

Hmm, I didn't mean that comment to be as whiny as it may have sounded. Sorry about that.

[Megan Oltman]

MJ you don't sound whiny at all. You inspire me. When I have trouble moving with my #2 head pain I think of you with your daily #5, starting a career, in a great new (well new compared to 22 years) relationship - I think of you and I keep on going - you are a hero in my book!

[Migraine Chick]

I'm in the no-rescue boat either. The side effects of Triptans knock me for a loop. I'm looking forward to your post about the lack of qualified headache specialists. I've yet to find one.

[claudine hellmuth]

glad to have found your blog! I can relate!
My Dr prescribes me 100mg of imitrex and then i cut them in 1/2 so I get 18 pills instead of 9 a month that just about lasts me. most times the 50mg can get me out of a migraine attack.