Headache rescue medication

Reviewing rescue medication and tolerance

We typically divide episodic treatments into abortive medication and rescue medication. Here we discuss rescue medication.

Most rescue medications are pain medications. Rescue medications won’t abort a migraine, but hopefully they will mask the pain for a few hours until the migraine runs its course. Rescue medications are intended for use in cases of abortive medicine failure. They also are needed when one can’t take the abortive medications, for instance when the time frame for treatment with an abortive agent has passed.

Common rescue medications for headaches

Common rescue medications include opioids, the antipsychotic olanzapine, and the opioid agonist-antagonist tramadol, which has serotonin and norepinephrine effects.

Rescue drugs can be used in isolation or in combination with triptans, for instance when there is frequent rebound on a triptan.

Fioricet (combination of acetaminophen, butalbital, and caffeine) and Amidrine (acetaminophen, dichloralphenazone and isometheptene) are examples of combination medicines that have been used as rescue medications. When used in this complimentary manner, keep in mind that an adequate dose is necessary.

Over-the-counter medications

Some patients find that, if taken early, some over-the-counter medications can be effective, for example, Paracetamol (acetaminophen), and combinations with caffeine and aspirin, and some nonsteroidal anti-inflammatory drugs (NSAIDs).

Toradol (ketorolac)

Toradol injections can be used to treat acute headaches and some patients can administer this drug themselves intramuscularly or subcutaneously

Corticosteroids

Years of experience suggest that in the acute setting, corticosteroids can be helpful to ameliorate acute migraine headache. However, there is not much direct evidence of its efficacy and even less as to mechanism of action. The presumed effect is on perivascular neurogenic inflammation in the meninges caused by the trigeminal complex cascade.

Dexamethasone (4 mg) has been used with success. Prednisone, starting with a high dose followed by a rapid taper over 10 days can also be effective.

Triptans

Triptans will relieve nausea in many patients. When they do not, antiemetics are helpful. These drugs antagonize dopamine receptors and thus can treat migraine directly, decreasing pain.

References

• The International Classification of Headache Disorders 3rd edition
• Rizzoli PB. Acute and preventive treatment of migraine. Continuum (Minneap Minn). 2012 Aug;18(4):764-82
• Mauskop A. Nonmedication, alternative, and complementary treatments for migraine. Continuum (Minneap Minn). 2012 Aug;18(4):796-806.
• Parikh SK, Silberstein SD. Calcitonin gene-related peptide monoclonal antibodies. Practical Neurology. 2018; 17: 20–22.
• Tepper SJ, Tepper DE. Neuromodulation and headache. Practical Neurology. 2018; 17: 42–45. 
• Natekar A, Malya S, Yuan H, Nahas S. Migraine Preventative Therapies in Development. Practical Neurology. 2018; 17: 54–57.
• Blumenfeld AM. Botox for chronic migraine: Tips and tricks. Practical Neurology. 2018; 17: 27–36
• Halker Singh RB, Starling AJ, VanderPluym J. Migraine acute therapies. Practical Neurology. 2019; 17: 63–67
• Krel R, Mathew PG. Procedural treatments for headache disorders. Practical Neurology. 2019; 17: 76–79.
• Motwani M, Kuruvilla D. 2019. Behavioral and integrative therapies for headache. Practical Neurology. 2019; 17: 85–89

Neurology Library: Headache – Treatment

• Coni R. Headache treatment. LITFL
• Coni R. Headache treatment: Prophylactic medication. LITFL
• Coni R. Headache treatment: Prophylactic medication (2). LITFL
• Coni R. Headache treatment: Abortive medication. LITFL
• Coni R. Headache treatment: Rescue medication. LITFL
• Coni R. Headache: Diagnostic challenge. LITFL