Nasal Sprays for the Treatment of Migraine
Nasal sprays can provide relief to migraine patients in as soon as 15 minutes, and are especially useful with nausea and vomiting, or in those who seek to avoid an injection. They are sprayed into the nostril with the head upright. Vigorous sniffing or tipping the head backward puts the medicine down the throat, turning a spray into an oral medication and losing advantages of rapid nasal delivery.
There are several categories of nasal spray treatment. Nasal triptans (sumatriptan and zolmitriptan) and dihydroergotamine (DHE), contain migraine-specific treatment. Triptans and DHE are highly effective but do cause blood vessel narrowing and should not be used in people with known or suspected vascular disease. A third nasal option is a non-steroidal anti-inflammatory (NSAID) spray, nasal ketorolac, containing medicine targeting migraine inflammation.
Many patients have an oral acute treatment for slower onset mild-moderate migraines without vomiting, and a nasal formulation for faster wakeup, throw-up, or more severe migraines. With this plan, one must be careful to choose oral treatment compatible with the nasal spray. Different triptan types cannot be safely mixed, and triptans and DHE also cannot be combined.
An anti-inflammatory nasal spray, tablet, or liquid can be mixed with either oral or injectable triptans, or with DHE. This combination of triptan or DHE plus NSAID may improve the benefits of both drugs, reversing inflammation and blood vessel dilation. This may prevent recurrence. Nasal DHE or NSAID migraine treatment sometimes works even late in a migraine. Triptans may be less effective when a patient wakes up with a migraine progressed to “central sensitization,” where everything hurts, including light, noise, touch, and smells. As many as 40% of patients do not respond to triptans, and nasal DHE or nasal ketorolac may be quite helpful.
Both nasal DHE and nasal ketorolac can be used for “rescue,” when a migraine has progressed out of control after several days of usual treatment and may spare you infusion therapy, steroids, or repeated injections. The non-narcotic sprays discussed are not habit forming, don’t cause drowsiness, and don’t cause the jitteriness and increased risk of bone loss associated with steroids.
TRIPTAN NASAL SPRAYS
A single spray of nasal sumatriptan (IMITREX) or zolmitriptan (ZOMIG) can work as early as 15 minutes compared to 6 minutes with injection or about 30 minutes with oral tablets. Liquid diclofenac also has onset at 15 minutes, but can be vomited. Nasal triptans can be useful for adolescents who vomit, as injections may be unacceptable for this age-group.
Nasal sumatriptan is approved for use in adolescents in Europe, but does not have US FDA approval for teens. Nasal sumatriptan is particularly unpleasant tasting, so special counseling must be done to avoid sniffing and swallowing. Nasal zolmitriptan is not approved for adolescent use by regulatory authorities.
Because of more acceptable taste, nasal zolmitriptan is often the nasal triptan of choice for patients with episodic migraine with quick onset or vomiting.
Nasal DHE (Migranal, Valeant Pharmaceuticals International, Aliso Viejo, CA, USA) is administered with 1 spray both nostrils, repeated in 15 minutes (4 sprays = one dose) Onset is slower than a triptan, but it can be used late in migraine, to prevent recurrence, and to help a patient out of rebound or medication overuse headache. Nasal DHE should not be used within 24 hours of a triptan.
Nasal ketorolac (Sprix, Regency Therapeutics, Shirley, NY, USA) is the only nasal NSAID currently marketed, and is FDA approved for moderate to severe pain. It can be used alone or combined with triptan/DHE to boost its benefits when treating tough migraine. Nasal ketorolac may also be used as rescue, and is approved for up to 5 days for acute pain. Ketorolac comes in both tablet and injectable (Toradol, Hospira, Inc., Lake Forest, IL, USA), and is frequently used in ERs and offices to break difficult migraines.
Prescribing information for all NSAIDs warns against use in patients with known or suspected coronary artery disease, and nasal ketorolac is no exception. Unlike triptans and DHE, NSAIDs cause no blood vessel narrowing, but can still increase risk of heart attack and stroke. Nasal ketorolac should not be mixed with other NSAIDS such as ibuprofen, diclofenac, or naproxen on the same day.
If you vomit with migraines, get full-blown migraines upon awakening, or want rapid relief without injections, consider a nasal spray. Options include triptans (zolmitriptan [Zomig] or sumatriptan [lmitrex]), DHE (Migranal), or an NSAID (Sprix).
Deborah E. Tepper, MD
Center for Headache,
Cleveland, OH, USA