Are tablets my only option?
I have fast rising attacks with early nausea or vomiting. I do not keep the tablets. Are there other options for me?
Many people with migraine have nausea or in some cases even vomiting with their attacks.
For this reason, medications that are ingested may not stay there long enough to be absorbed in the blood and be effective. Even if there is no nausea yet, migraine often slows down the digestive movements, and slows down the absorption of tablets. Options that can be absorbed quickly and without digestion are useful for those attacks. A drug that bypasses the digestive system and reaches the blood by other ways is called parenteral (beside the gut).
An injectable form of sumatriptan (Imitrex) is available. It is designed for injection at home by the patient. For most people with migraine, it works more quickly than the tablets. It is however quite expensive, and most patients prefer to avoid injections if possible. It can be a very good option if you wake up with migraine attacks that are already fully developed and which do not respond to tablets. The injections can also be very useful if the migraine attacks during the day build up very quickly, or if there is vomiting early in the attack. If you vomit up a pill you have just taken, then the pill will not work very well for you. If this tends to happen to you during some attacks, the injectable form may need to be considered. Injecting yourself may sound scary, but your doctor and pharmacist can help you to learn how to master the necessary equipment and techniques. An injectable form of DHE is available as well. It is less expensive, but somewhat more complicated to use.
There are also two nasal spray triptans, sumatriptan (Imitrex) and zolmitriptan (Zomig), available in Canada, and DHE is also available in a nasal spray, Migranal. The nasal sprays can be quite helpful in patients with nausea, because some of the drug, especially in the case of zolmitritpan, is absorbed through the nasal mucous membranes, and therefore does not need to go through the stomach. Unfortunately, overall much of the drug is still absorbed through the stomach as it is swallowed with the saliva. Therefore, if a patient is actually vomiting, the nasal spray may not work well for that reason. Because some of the drug is absorbed through the nose, the triptan nasal sprays can work very quickly for some patients.
Two of the triptans are also available as tablets that dissolve in the mouth. These are referred to as wafers, Maxalt RPD or orally dissolving or melting tablets, Zomig Rapimelt. They have their advantages, as it is not necessary to take water with them. Therefore if you have nausea, and drinking some water just might bring on vomiting, these tablets may be for you. Also, if you find that you respond much better if you take your triptan medication early in the attack, then these preparations that dissolve in the mouth may be useful, as you can take them even if water is not available to you, for example in the car. Although you might also think that, because they dissolve in the mouth, these tablets might be faster than the regular tablets that are meant to be swallowed, this is not the case. These special tablets do dissolve in the mouth, but they are not actually absorbed through the mouth lining. Instead, they go down to the stomach as you swallow your saliva, and are absorbed in the usual way through the gastrointestinal tract. They are therefore no faster than the regular tablets, and if you vomit early in the attack, they also may not be effective for you.
Anti-inflammatories powders, suppositories and injections
Diclofenac potassium has recently been marketed under the name Cambia. Diclofenac is also known under the name Voltaren. Cambia is a fine powder that is dissolved in 2 ounces of water. The advantage of this drug is that it is absorbed rapidly in the stomach and hits the blood in 15 minutes. Most oral drugs take 30 minutes to 2 hours to reach the blood. The powder tastes like mint mixed wth aniseed.
Naproxen and indomethacin exist in suppository form. The suppository, inserted in the rectum, is absorbed in the rectal veins and therefore bypasses the digestive system. If NSAIDs are useful but the oral form is not kept in, rectal forms can be used.
Ketorolac (Toradol) is an NSAID that can be injected in the muscle (intra-muscular or IM). It is used in the emergency department but with some training a patient can self-administer at home. The usual dose is 30 mg. A nurse can teach you how to use it.