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capable of causing drug dependence; therefore we have prescribed it sparingly Numerous other agents have proved to be effective and each has had a period of popularity among neurologists (the review by Schulman and Silberstein is recomended) Overall, for severe attacks, sumatriptan or one of the newer triptans (eg, zolmitriptan, rizatriptan, etc) and the ergot alkaloids, ergotamine tartrate, and particularly dihydroergotamine (DHE), are probably the most effective forms of treatment and are best administered early in the attack A single 6-mg dose of sumatriptan or its equivalent [selective agonists of serotonin (5HT) receptors], given subcutaneously, is an effective and well-tolerated treatment for migraine attacks An advantage of sumatriptan, and now of some others in this class, is the ease of self-administration using prepackaged injection kits, thus avoiding frequent and inconvenient visits to the emergency department.

Sumatriptan can also be given orally in a 50- or 100-mg tablet, zolmitriptan in a 25- or 5-mg tablet, and rizatriptan in a 10mg dose repeated, if needed, in 2 h (and other similar drugs in this class), but their latencies for headache relief are longer than that of the subcutaneous injection A tabulated comparison of the triptan drugs is given in the review by Goadsby and colleagues; others in this class are sure to be developed and subtle differences between them undoubtedly will be touted, but these are usually negligible in practical terms Sumatriptan is available as a nasal spray, which is particularly useful in patients with nausea and vomiting The response rate after 2 h is similar to that of the orally administered drug, and the nasal spray acts more rapidly.

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Ergotamine is an equally effective agent, but some safety issues and aggressive marketing of the triptans have reduced its use This is an alpha-adrenergic agonist with strong 5HT receptor af nity and vasoconstrictive action The drug is taken as an uncoated 1- to 2-mg tablet of ergotamine tartrate, held under the tongue until dissolved (or swallowed), and repeated every half hour until the headache is relieved or until a total of 8 mg is taken A single oral dose of promethazine (Phenergan) 50 mg, or of metoclopramide (Reglan) 20 mg, given with the ergotamine, relaxes the patient and allays nausea and vomiting Patients in whom vomiting prevents oral administration may be given ergotamine by rectal suppository or DHE by nasal spray or inhaler (one puff at onset and another at 30 min) or can learn to give themselves a subcutaneous injection of DHE (usual dosage, 1 mg).

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Caffeine, 100 mg, is thought, on slim evidence, to potentiate the effects of ergotamine and other medications for migraine When ergotamine is administered early in the attack, the headache will be abolished or reduced in severity and duration in some 70 to 75 percent of patients For severely ill patients who arrive in the emergency department or physician s of ce, having failed to obtain relief with the usual medications, Raskin has found metoclopramide 10 mg IV, followed by DHE 05 to 1 mg IV every 8 h for 2 days, to be effective We also use this approach in cases of status migrainosus Intravenous and oral corticosteroids have also been useful in some refractory cases and as a means of terminating migraine status, but they should not be given continuously.

The potential success of metoclopropamide should not be dismissed, as we and others have occasionally found that the headache abates after this initial injection The sympathomimetic drug isometheptene combined with a sedative and acetaminophen (Midrin) has been useful for some patients and probably acts in a similar way to ergotamine and sumatriptan A wide array of other drugs has been recommended as adjunctive therapy, eg, metoclopramide, prochlorperazine, chlorpromazine, ketorolac, and intranasal lidocaine Even anticonvul-.

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