Ask the Pharmacist Archive - Issue #165
Multiple Medications for Migraine Attacks
Q: My doctor prescribed several medications for my migraine attacks, including naproxen tablets, zolmitriptan nasal spray and droperidol injections. Which medication should I use first?
A: Your healthcare provider is wise to prescribe multiple treatment choices. All migraine patients should have at least two medication options for their attacks. Unfortunately, far too many people only have one drug and end up suffering in instances when the drug does not help.
Deciding how quickly you need your medication to take action is probably the best way to approach this question. In terms of speed of onset of action, the rankings are 1) injectable, 2) nasal spray and 3) pill/tablet.
For example, if you awake in the morning with a severe attack, then you obviously want a drug that will have effects as fast as possible. In this case, your injection would be your best choice, although your nasal spray could also be an option. On the other hand, if during the day you feel an attack slowly building and know that later in the day you will have significant pain, a pill would be a reasonable first choice.
Another important consideration is when to use an additional drug if the first medication fails to provide relief. As a general rule, shots and nasal sprays reach full effect within one to two hours, while medications taken by mouth need two to four hours. Thus, you should wait at least the appropriate amount of time to ensure that the medication has had a chance to work prior to consuming another medication.
Here are some other factors to consider. Pills and tablets are clearly poor choices if you have nausea and vomiting; a shot, nasal spray or even a suppository would be better. A drug's side effects are important. For example, a medication that makes you drowsy is obviously a poor option if you need to be fully alert to perform work or other important tasks (like driving). However, this medication may work well if you are about to go to bed anyway. With time you will undoubtedly gain the experience needed to match the appropriate medication for your particular needs at a specific moment.
Difference Between Delayed-release and Extended-release Depakote®
Q: Recently there was some confusion at my pharmacy regarding my Depakote tablets. The pharmacist had to call my doctor to ask about delayed-release versus extended-release tablets. Are these the same thing?
A: Unfortunately, there has been a great deal of confusion surrounding these medications. There are important differences between these two tablet formulations, even though they both contain the same active drug ingredient, which is divalproex sodium.
Depakote delayed-release tablets have been available for more than a decade. They are FDA approved and widely prescribed to treat seizures and migraines, as well as a few other illnesses. When healthcare professionals say “Depakote,” they are actually talking about Depakote delayed-release tablets.
Depakote extended-release gained FDA approval for the prevention of migraine attacks approximately five years ago and this is when the confusion began because the names sound similar. Furthermore, both are available in 250 mg and 500 mg tablets, which only adds to the confusion.
The key difference between these products is that Depakote extended-release is administered only one time per day, but Depakote delayed-release can be given two or three times per day. Patients should not be confused that “delayed release” implies only once per day, because this is incorrect.
If you mistakenly receive the wrong tablet formulation, this could lead to either too much medication in your blood, which can cause more side effects, or too little drug in your blood, decreasing the medicationÕs effectiveness. Therefore, all patients should clarify with their healthcare provider exactly which tablet formulation they should get. Double-check that you receive the correct formulation from your pharmacy.
Lastly, if needed, your healthcare provider can order a blood test to measure the amount of medication in your blood to help determine if a dose change is necessary.
We welcome your medication-related questions for this column. Address them to Ask the Pharmacist, NHF Head Lines, 820 N. Orleans, Suite 411, Chicago, IL 60610-3132, or email them to NHF1970@headaches.org. Please write “Ask the Pharmacist” in the subject line.
Rich Wenzel, Pharm.D., Diamond Headache Clinic Inpatient Unit, St. Joseph's Hospital, Chicago, IL