Use in Adults
Combinations
THIS GUIDE PROVIDES A PARTIAL LISTING OF PRESCRIBING INFORMATION FOR THIS MEDICATION. FOR A FULL LISTING OF PRESCRIBING INFORMATION PLEASE REFER TO THE PACKAGE INSERT. CLICK ON THE BRAND NAME® TO VIEW THE LINK TO THE PACKAGE INSERT.
Acetaminophen + Aspirin + Caffeine (Excedrin®, Excedrin Migraine®) Click here to expand
Brands:
Excedrin® Excedrin Migraine® For Complete Prescribing Information Click Here for the Package Insert
Initial Dose:
Excedrin® Excedrin Migraine® For Complete Prescribing Information Click Here for the Package Insert
Initial Dose:
- Acetaminophen 250 mg / ASA 250 mg / Caffeine 65 mg
- 2 tablets by mouth at onset of migraine as needed for the treatment of an acute migraine attack.
- May be repeated in 6 hours as needed if attack inadequately treated if using Excedrin XS, but only two tablets in 24 hours if using Excedrin Migraine
- For Excedrin Migraine, only 2 tablets in 24 hours
- For Excedrin XS (extra strength), two tablets may be taken every 6 hours, total of 8 tablets in 24 hours
- For generic products, two tablets may be taken every 6 hours, total of 8 tablets in 24 hours
- Heartburn, stomachache, nausea, headache, feeling jittery, trouble sleeping
- The FDA approved Excedrin for acute migraine treatment in 1998. It should be noted that the medication was only studied in individuals with mild to moderate migraine attacks as the studies excluded those with vomiting in >20% of attacks and those whose migraines required bedrest for more than 50% of attacks.
- Most headache specialists feel that these medications are probably most appropriate as a primary acute therapy for those with mild to moderate attacks of migraine, but it can work with severe attacks in some patients.
- Since this medication is over-the-counter patients have often tried this medication before presenting to their health provider and thus, may not be an appropriate choice in patients with moderate to severe attacks, and not in those with nausea and vomiting.
- Advantages are low cost, good efficacy for mild-moderate attacks and over-the-counter availability.
- A major disadvantage is its risk for medication overuse headache due to its easy accessibility. To avoid medication overuse headache, use should be limited to 10 or fewer days per month.
- Drug reaction with eosinophilia and systemic symptoms, GI effects, hepatotoxicity, hypersensitivity reactions, skin reactions
- Keep dosage of acetaminophen dosage to less than 4000 mg per day to prevent hepatotoxicity
- Avoid or use cautiously in those with a history of peptic ulcer disease
- Avoid in those with kidney and hepatic disease
- Risk of peptic ulcer disease increased in the elderly population
- Allergy to acetaminophen, aspirin or caffeine that are contained in this medication.
- Click Excedrin Migraine® and navigate to If Pregnant or Breast-Feeding under WARNINGS
- Aspirin, NSAID, cyclosporine, tenofovir disoproxil fumarate, isoniazid, SSRIs, desvenlafaxine, isoniazid, venlafaxine, acetaminophen and pneumococcal 13-valent vaccine, diphtheria conjugate, thiazide diuretics, loop diuretics, anticoagulants among most prominent ones.
- Limit use to 2 days per week to avoid medication overuse headache
Naproxen + Sumatriptan (Treximet®) Click here to expand
Brands:
Precautions and Risk:
Counseling Tips:
- Treximet® (sumatriptan succinate and naproxen sodium) For Complete Prescribing Information Click Here for the Package Insert
- 500 mg naproxen+ 85 mg sumatriptan in a fixed dose combination tablet
- 500 mg/85 mg by mouth at onset of migraine, may repeat in 2 hours if headache inadequately treated
- 1,000 mg naproxen sodium + 170mg sumatriptan
- Triptan side effects such as paresthesias, tightness in throat, chest pain/discomfort, dizziness and somnolence as a result of the sumatriptan.
- Upset stomach, heartburn, nausea, drowsiness as a result of the naproxen
- This drug is a fixed dose combination of sumatriptan and the NSAID, naproxen sodium. One advantage is that its naproxen sodium gives it a longer duration of action than sumatriptan alone.
- Patients who respond inconsistently or partially to NSAIDs or patients who have not responded to triptans in the past, may benefit from its use. Non responders to triptans were shown to respond to this medication in >50% in subsequent trials.
- Side effects include those of its components, see above.
- Would avoid use in those with cardiovascular disease (CAD, stroke, Prinzmetal’s angina, peripheral vascular disease, mesenteric ischemia), history of peptic ulcer disease or renal failure or in those with basilar-type or hemiplegic migraine.
- Treximet should be used with caution in those with two more cardiovascular risk factors. Some clinicians recommend cardiac evaluation to exclude unrecognized cardiovascular disease prior to use of sumatriptan or other triptans in patients who have two or more cardiovascular risk factors.
- Main advantages are good efficacy, a long safety record for use and a lower likelihood of headache recurrence 2-24 hours after its initial dosage.
- Main disadvantages are a higher incidence of side effects and the potential need to screen those with migraine for cardiovascular or other vascular risk prior to use of the triptans.
Precautions and Risk:
- Avoid in those with aspirin allergy
- Risk of peptic ulcer disease with frequent use
- May exacerbate hypertension
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- In clinical trials, patients on daily regular dose aspirin were allowed to continue its use, as this fixed dose combination of sumatriptan/naproxen sodium is only scheduled for intermittent use
- If you are allergic to aspirin other pain relievers/fever reducers or any component of the formulation
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, hemiplegic or basilar type migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Click Treximet® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Sumatriptan:
- Do not use within 24 hours of another triptan or ergotamine
- Pharmacists frequently report a drug interaction between triptans and anti-depressants because of the risk of serotonin syndrome. However, this is felt to be a theoretical risk. Sufficient evidence to support the contention that combined use of triptans and serotonergic anti-depressants is unsafe has not been established. This is reflected in a position statement from the American Headache Society (Evans R. Headache 2010; 50: 1089-99) Therefore, headache physicians commonly co-administer antidepressants and triptans in the same patient.
- Naproxen
- Ketorolac: Concurrent use may result in enhanced gastrointestinal adverse effects (peptic ulcers, gastrointestinal bleeding and/or perforation).
- Tricyclic Antidepressants/SSRIs/SNRIs: Concurrent use may result in an increased risk of bleeding, although rare
- Warfarin: Nonsteroidal anti-inflammatory agents (nonselective) may enhance the anticoagulant effect of vitamin K antagonists.
- Direct oral anticoagulant medications (DOACs): NSAIDs may enhance the adverse/toxic effect of these drugs. Specifically, the risk of bleeding may be increased
- Potassium-sparing diuretics: Concurrent use may result in reduced diuretic effectiveness, hyperkalemia, or possible nephrotoxicity.
- Cyclosporine: NSAIDs may enhance the nephrotoxic effect of cyclosporine
- Tacrolimus: Concurrent use may result in acute renal failure.
- Methotrexate: NSAIDs may increase the risk of methotrexate toxicity (leukopenia, thrombocytopenia, anemia, nephrotoxicity, mucosal ulcerations).
- Lithium: NSAIDs may increase the serum concentration of lithium.
- Tenofovir: Concurrent use may result in increased risk of acute renal failure.
- Desmopressin: Concurrent use may result in increased risk of hyponatremia.
Counseling Tips:
- None