Ativan-Benadryl-Haldol-Reglan Gel for Migraine

Steve Toney, RPh
Erin King, CPhT
MyrtleTowne Pharmacy and
Henderson Center Pharmacy
Eureka, California

Migraine is a debilitating condition. The cost of migraine to American employers is estimated to be about $13 billion a year, $8 billion of which is attributed to missed work days.(1) There is no "gold standard" for the diagnosis of migraine, but the International Headache Society Criteria for the Diagnosis of Migraine has published inclusion and exclusion criteria for use in diagnosis.(2)

A 26-year-old woman who became our patient was involved in an automobile accident in August 2000. Before that incident, she had had no history of migraine. One to 2 weeks after the accident, she experienced a throbbing frontal lobe pain, which is characteristic of migraine, above her eyebrows. Approximately 2 hours later, her field of vision was interrupted by muscae volitantes, and she experienced nausea that continued for 5 or 6 hours, after which she vomited intermittently over a 4 to 5 hour period. A low-grade headache interrupted by episodes of migraine then became ongoing.

This patient had not been examined by a physician (since the accident) until approximately 1 week after the onset of headache. At that time, she was not taking medication and had not initiated self-prescribed treatment because she thought that her symptoms were caused by a viral infection. Examination by her physician resulted in a diagnosis of migraine, for which treatment with butalbital-caffeine-acetaminophen (50/40/325 mg, respectively; Fioricet) at a dose of 1 to 2 tablets every 4 hours as needed was prescribed. The physician also prescribed tramadol (Ultram) 50 mg, 1 tablet every 6 hours as needed (to be taken if the butalbital compound was ineffective within 3 hours).

The low-grade headache produced insomnia, for which nortriptyline (Pamelor) was prescribed in the following dosage: 10 mg (1 capsule) at bedtime for 3 days, then 20 mg at bedtime for 3 days, and then 30 mg at bedtime for 3 days. The patient has continued the 30-mg dosage as a maintenance protocol. In addition, the physician prescribed physical therapy 3 times per week for 12 weeks and biofeedback therapy to treat the patient's sprained muscles of the head, neck, and back.

Results of the biofeedback therapy, which was performed at the beginning and end of physical therapy sessions, indicated that the patient's sitting and standing posture did not precipitate or exacerbate her migraines. The physician then prescribed treatment with transdermal electronic nerve stimulation as needed for additional pain control.

During the subsequent 2 months, this patient endured a constant, nagging headache that on two occasions evolved into a migraine of several days'duration. Two to 3 times per month, the headache was so severe that she was incapacitated, was absent from work, and spent weekends bedridden in a dark room. During one episode of migraine, she lost consciousness while she was in the shower, after which she was absent from work for 2 days. In November 2000, she was referred to a neurologist. A neurologic evaluation in January 2001 included magnetic resonance imaging (MRI), but the results revealed no visible abnormalities of or injury to her head or neck. The patient then returned for treatment to her general practitioner, by whom she had been evaluated every 2 weeks since the onset of the first migraine.

This patient requested something stronger than Fioricet or Ultram for the treatment of headache pain, and after evaluating the information from the neurologist, her general practitioner prescribed sumatriptan (Imitrex) 5-mg nasal spray and hydrocodone/ibuprofen 7.5/200 mg (Vicoprofen), 1 to 2 tablets every 6 to 8 hours as needed. The patient was instructed to use 1 spray of the Imitrex at the onset of headache and to repeat the spray 2 hours later if necessary, but the dosage was not to exceed 20 mg (4 sprays) per week. She also requested treatment for the nausea that accompanied the headaches and received a prescription for prochlorperazine (Compazine), one 10-mg tablet of which was to be taken every 4 hours as needed for nausea and vomiting. The patient chronicled the occurrence of her migraines and her response to treatment and determined that the nausea accompanying each migraine was caused by the Imitrex nasal spray, which ran down her throat. To alleviate that nausea, she had been taking Compazine, but she usually vomited shortly thereafter. That vomiting continued and spiraled into hours of nausea and vomiting that increased the severity of the headache, sometimes for days.

The patient realized that controlling the initial bout of nausea would avert the subsequent cycle of nausea and vomiting. She wanted treatment other than rectal suppositories, and she found information about compounded gels used to alleviate nausea, vomiting, and anxiety in hospice patients. She then consulted with her physician about using Ativan-Benadryl-Haldol-Reglan (ABHR) topical gel, which he prescribed at a dosage of 1 mL to be applied topically every 4 to 6 hours as needed.

In May 2001, 2 weeks after obtaining the ABHR gel, the patient's low-grade headache erupted into a migraine, for which she took Imitrex and Compazine as prescribed. She vomited almost immediately. She then applied 1 mL of the ABHR gel (0.5 mL) to each wrist and rubbed her wrists together. After 15 minutes, the nausea and migraine resolved completely, and she experienced no vomiting.

At present, this patient continues to use Imitrex nasal spray to treat migraine, after which she immediately applies the ABHR gel to her wrists and rests for 15 minutes. That treatment eliminates headache and prevents nausea and vomiting. She has been able to return to her normal lifestyle and was not absent from work for health-related reasons during the 6 months after treatment with ABHR gel was implemented. At the time of this writing, she is continuing treatment with nortriptyline 30 mg at bedtime and uses no pain medication except for an occasional tablet of Fioricet (to treat the low-grade headache) approximately once each month. This patient has told friends and colleagues about her successful treatment, and her physician is now prescribing ABHR gel for other patients who suffer from migraine.

References
1. Hu XH, Markson LE, Lipton RB, et al. Burden of migraine in the United States: Disability and economic costs. Arch Intern Med 1999;159:813-818.
2. Loder E,Tietjen GE, Marcus DA. Evaluation and management issues in migraine. JCOM 1999;6:58-76.

excerpt from RXTriad, December 2001