Compound Medications for Acute Migraine Treatment

Compound medications – those containing 2 or more drugs in a single tablet or capsule – are nothing new to the treatment of acute migraine headache. Butalbital-containing compounds (those blending that drug with aspirin or acetaminophen and – often – caffeine) long have been prescribed – and decried – by clinicians who treat patients with headache, and Cafergot, an ancestor of the now-popular sumatriptan (Imitrex) and containing ergotamine tartrate and caffeine, was for years a mainstay of acute migraine therapy in headache clinics throughout the world.

Many of the over-the-counter (OTC) preparations intended for acute headache treatment are compounds containing aspirin, acetaminophen, and caffeine (eg, Excedrin, Goody powders), and used judiciously these can be quite effective when taken during the early stage of a migraine attack. Unfortunately, in those with migraine, overuse of the butalbital-containing compounds or the easily accessible OTC preparations is common and may lead to medication overuse headache (popularly known also as “rebound” headache) and clinical worsening of one’s headache disorder.

Some compounds reflect an effort to treat both migraine headache and the nausea that may accompany migraine or represent a side effect of the compound’s other component; an example of this is the combination of promethazine (Phenergan) and meperidine (Demerol) in drugs such as Mepergan and Meperzine. Other compounds have been formulated in the hope that the different components will act in a complimentary fashion to relieve headache, and one widely used example is the combination of isometheptene (a drug which weakly constricts blood vessels), acetaminophen (a non-specific “simple analgesic” for pain relief), and dichloralphenazone (a muscle relaxant); this compound has been marketed under various names (eg, Midrin).

For years many physicians who practice headache medicine have advised their patients to take one of the 7 commercially available oral triptans and a nonsteroidal anti-inflammatory drug (NSAID; eg, naproxen sodium, indomethacin, ibuprofen) together for an acute migraine. An intriguing new prescription compound for acute migraine treatment was approved for general use in the spring of this year. Treximet is a combination of naproxen sodium 500 mg and sumatriptan 85 mg wedded in a unique formulation that appears to be more effective in suppressing acute migraine than either component taken alone. Whether the Treximet compound may be more effective than a triptan and NSAID taken separately but simultaneously remains something of an open question, but the former obviously offers the advantage of convenience.

In closing, it should be emphasized once again that overuse of medication intended for acute migraine treatment may lead to an overall worsening of one’s headache disorder and the development of near-daily, daily, or even constant head pain. If you find yourself using such medication more than 4 or 5 days per month, it’s time to speak with your medical provider about potentially beginning therapy for migraine prevention.

John F. Rothrock, MD

Editor-in-Chief, Headache