The Combination Principle
Your migraine attacks just won’t break with one medication? Try two! Some migraine attacks are difficult to treat. The migraine attack is a chemical and electrical storm in the brain that leads to pain and a wide variety of accompanying symptoms (See this post).
The key options for the acute treatment of migraine are anti-inflammatories or NSAIDs and triptans (See this post).
Why would it be best to take two medications instead of one?
NSAIDs and triptans and gepants have different chemical mechanisms. The NSAIDs work on the inflammation (prostaglandin system, to be exact), and the triptans on the serotonin system AND the CGRP system. Gepants act on the CGRP system. Therefore, their actions combined offer a better chance of success.
Is it dangerous to take two medications at the same time?
Every person is different, but unless you have contraindications to either medication, you can safely combine them. Always check with your health care provider.
Is there more risk of medication overuse if I combine triptans and NSAIDs?
The critical factor for the overuse phenomenon is the number of days per month that you use acute medications (See this post). Remember that if your treatment is successful, you may end up with fewer days of migraine per month. For example, your attack may last only one day instead of three.
Can I combine gepants with acute medications?
Gepants are more recent options. In theory, they can be combined with other treatments but check with your health care provider for your specific situation. Gepants do not lead to medication overuse headache so they can be an interesting option for people with frequent attacks (See this post).
I have been warned about the risk of overuse with combination analgesics like Fiorinal. What are those?
Combination analgesics usually contain either acetaminophen or aspirin, codeine, and caffeine. Another famous compound, Fiorinal, also contains barbiturates. These medications are linked with a high risk of chronification, primarily because of the opioids and barbiturates . Some people also tend to see them as benign drugs and use them often, even if they do not work very well.
Are there medications that contain a triptan and an NSAID simultaneously?
Yes, in Canada, we now have Suvvex, a combination of sumatriptan and naproxen that was approved by Health Canada. In the United States, it is called Treximet.
Can I use other medications, for example, acetaminophen and anti-nausea drugs?
In theory, you can. This being said, acetaminophen is not a very powerful treatment for migraine and rarely adds a great benefit. Anti-nausea drugs (Gravol, Stemetil, Metonia) may help you to control nausea and avoid vomiting so that your other medication is better absorbed. (See this post)
Remember: you do not have to combine all the time!
Most migraine patients have different types of attacks. Some are milder, and some are very severe. If you know from experience which attack is coming, you can adapt your treatment to fit your attack severity. Is it going to be a mild attack? Maybe an NSAID is enough. But if all your warning signs are there that this will be a severe attack, it is best to use the most potent combination.
REFERENCES
Mayans L, Walling A. Acute Migraine Headache: Treatment Strategies. Am Fam Physician. 2018;97(4):243-51.
Worthington I, Pringsheim T, Gawel MJ, Gladstone J, Cooper P, Dilli E, et al. Canadian Headache Society Guideline: acute drug therapy for migraine headache. Can J Neurol Sci. 2013;40(5 Suppl 3):S1-s80.
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