Medication Therapy

Oral medications for prevention of headaches

There are a number of categories of medications used to prevent headaches and facial pain. Below are
listed the important categories with some names of medications:

Beta blockers
– Propranolol, atenolol, metoprolol, nadolol.
These tend to lower heart rate and blood pressure but are very well tolerated and effective.

Tricyclic antidepressants – Amitriptyline, nortriptyline, doxepin.
Most of these are in fact not use much for depression but are quite useful in a migraine, tension-type headache, and neuralgia. Side effects tend to be some sedation, dry mouth and possible increased appetite.

Other antidepressants - venlafaxine, duloxetine.
These are a bit less useful than the tricyclics but are nonetheless effective for some.

Antiepilepsy medications – topiramate, valproate, gabapentin, zonisamide.
While different members of this family have different properties they can all be very effective in a number of types of head pain. Side effects vary but a common thread is a tendency to produce some mild cognitive difficulty in some patients at higher doses.

Calcium channel blockers – verapamil, amlodipine.
These are sometimes effective in a migraine but can be particularly effective in cluster headaches.

Antispasmodics – baclofen, tizanidine.
These are best in pain due to nerve damage or irritation like neuralgias and are generally well tolerated but sedating.

Anti-CGRP monoclonal antibodies - erenumab, fremanezumab, galcanezumab.
This is a new and potentially very significant group of medications consisting of laboratory synthesized antibodies that block a chemical called calcitonin-gene-related peptide, a molecule that seems to lead to migraine attacks. They are administered in an injectable form and seem to be extremely effective for some patients, with very limited side effects.

Acute medications

These are used at the time of a headache for the express purpose of reduction of symptoms at the time. We not only target head pain but also nausea and vertigo.

Triptans – sumatriptan, naratriptan, rizatriptan, zolmitriptan, almotriptan, eletriptan, frovatriptan.
These are mainly available in oral form, but sumatriptan has an injectable form which can be used at home, and both sumatriptan and zolmitriptan have nasal spray forms.

Non-steroidal anti-inflammatory medications (NSAIDs) – ibuprofen, naproxen, diclofenac.
Mostly in pill form, these can be very effective though in general not as potent as triptans

Antiemetics – promethazine, prochlorperazine, ondansetron.
Nausea often becomes more disabling than the head pain and must be treated when it is severe. These can be used in rectal suppository form and ondansetron has a very effective under-the-tongue version.

Nerve blocks and trigger point injections

Both of these approaches involves injecting anesthetic medication in the head and or neck for acute relief, or more commonly, prevention of headaches.

Anesthetics - lidocaine, bupivacaine.
Treatments are done in the office and require very little preparation. The nerves targeted include the occipital nerves at the back of the head, supraorbital nerves in the forehead, and the sphenopalatine ganglion nerves on the sides of the head. The latter is done without a needle but with a catheter carefully inserted into a nostril. The muscles we target run mostly in the upper neck and near the jaw.