Migraine in the Athlete

Judy C. Lane, MD, The Head Pain Center, Englewood, Colorado.

Semin Neurol. 2000;20(2) 

In This Article

Treatment

The treatment plan can be divided into nonpharmacologic and pharmacologic approaches. Treatment plans should include education focusing on lifestyle changes and nutritional factors. The physician should be encouraged to involve the patient, parents, school coaches, and athletic trainers. Environmental and behavioral triggers should be identified and, as possible, reduced ( Table 2 ).

Biofeedback and stress management strategies have been helpful in some athletes, especially young athletes.

Athletes are often interested in nutritional factors (well-balanced diet and supplements). Supplements that might reduce the severity and frequency of migraine include:

1. Magnesium (chelated or citrate), 200 mg twice a day (b.i.d.). Foods high in magnesium include nuts, legumes, vegetables, whole-grain cereals and breads, and seafood; some of these foods may be migraine triggers.

2. Riboflavin 200, mg b.i.d. Foods high in riboflavin are dairy products, liver, meat, green vegetables, eggs, and dried beans and peas. The maximum effect of riboflavin on reducing headache frequency was seen at 3 months of treatment.7

When nonpharmacological approaches fail to control headaches, medications are required. Ideally, they should have minimal or no impact on athletic performance. Medications can be divided into preventive medicines and abortive medications.

Preventive Medicines

Preventive medicines are chosen if headache frequency is more than 2 days a week or if headaches are not easily aborted. Headache specialists differ in their recommendations. I favor the following approach:

1. Calcium channel blockers. Rationale for use: these drugs decrease the irritability of the pain generator. I start with nicardipine sustained release (SR), which has few side effects. Starting dose: 30 mg SR daily. Increase to twice daily in 1 week. Another option is verapamil. Side effect: constipation. If headaches persist, I add a selective serotonin reuptake inhibitor (SSRI).

2. SSRIs. Rationale for use: it is now known that migraineurs have an abnormality in serotonin function. I generally start with paroxetine or sertraline. Starting doses are paroxetine 10 mg daily and sertraline 25 mg daily, increasing to 50 mg daily in 1 week. Side effects: nausea and decreased libido.

3. Indomethacin. Rationale for use: acts as an anti-inflammatory and also as a nitric oxide antagonist. It can reduce intracranial pressure.20 Dose: for frequent headache: 25 to 50 mg three times daily. For infrequent headache, or headache only with exertion: 25 to 50 mg 1 to 2 hours before exerting. Side effects: can compromise renal function and potentiate the risk of developing acute renal failure. More likely to occur with dehydration or increased stress.21 Athletes should be warned of the potential of any anti-inflammatory drug to compromise renal function. Monitor renal function prior to use and at approximately 6- month intervals. Additional side effects: gastritis or ulcers.

Abortive Medications

Many of the new medications are migraine specific. This means that they inhibit neurovascular inflammation, and vasoconstrict dilated blood vessels. New medications are rapidly being added to our armamentarium. Do not use the medications for the first time during an athletic endeavor.

1. One of the oldest is dihydroergotamine (DHE). My initial recommendation is to use the nasal spray. Pain relief is often seen within one-half hour. Side effects of the nasal spray are minimal; nasal congestion the most frequent.

2. Triptans are an important addition to the therapeutic cabinet. The first one released was sumatriptan. I would again recommend starting with the nasal spray form. Dose: 20 mg. May be repeated in 1 hour. Side effects include chest tightness. Two newer triptans, zolmitriptan and rizatriptan, are well absorbed in pill form and may be effective in less than 30 minutes. Typical dose of zolmitriptan is 5 mg, repeating in 2 hours if necessary. Maximum dose, 10 mg per day. For rizatriptan, 10 mg at onset, repeating in 2 hours for a maximum dose of 30 mg per day. Side effects: drowsiness.

Prior to use of the migraine-specific medications, DHE or the triptans, the patient's medical history is reviewed. Men older than 40 and postmenopausal women should be screened for risk of cardiovascular disease. Because of vasoconstrictive effects, these medications are never used in the presence of coronary artery disease, uncontrolled hypertension, or pregnancy. In addition, these agents are contraindicated with hemiparetic migraine. Use of sumatriptan is being studied in children and criteria are being established for pediatric use.

3. Oxygen is sometimes useful abortively. It may be particularly useful at higher altitudes. It is administered by a mask, preferably nonrebreathing, at 100%. Its use can be combined with one of the preceding abortive medications. The mechanism of benefit is not clear.

4. Lidocaine 4% nasal drops are sometimes of benefit. Dose: full dropperful into nostril on the same side as headache. Repeat once after 5 minutes if needed. No more than three doses per day. Side effects: possible burning sensation. Mechanism: may inhibit the trigeminal nerve.

5. Anti-inflammatories. In addition to indomethacin, useful ones to try include diclofenac potassium, 50 to 100 mg at onset; oxaprozin, 600 to 1200 mg at onset; or etodolac, 500 mg at onset. Gastrointestinal side effects are common, but these choices are typically well tolerated.

6. Isometheptene. Dose: 2 at onset, 2 in 1 hour. Combination of a mild vasoconstrictor, mild sedative, and a mild pain suppressant. Side effects: sleepiness for some.

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