Hi,
I just recently started using the immitrex injections.  I read about the tip here, and have been splitting the dose 3-4 times depending on how strongly the ha is coming on.  Sometimes it works great, pain is gone quickly with no issues.  Other times it comes back, within a few hours. My norm is 1 ha a day, at most 2.  Not sure if maybe it's because I'm not giving myself enough or maybe I'm getting "rebound" ha.  Any help or suggestions would be greatly appreciated. Thanks!

If I understand, you may divide a 6mg dose into as
much as 4 doses  or 1.5mg per injection.

If so, likely this too small a dose to give sufficient action.

OR, if you are monitoring the attack before you decide the dose to use this leads to hitting a developing attack with some delay. Even with a full 6mg dose, a well developed attack (and they do develop rapidly, no?) may fail. The general "rule" is hit with an abortive (any of the commonly used ones) before it's well developed.

General idea: better to "waste" a dose responding at the first sign of an attack to a false alarm than to delay and experience failure to get relief by too much delay.

Thanks for the reply. I should've explained better. If I wake up and I'm already in pain, then I give myself more.  If I wake up to just the burning/stuffiness in my nose I give less, because I figure I  caught it sooner. 
Until I found this site I only had 1 abortive, zomig tablets, and I had to make 9 last 30 days. Now I also have the immitrex injections,  oxygen, and red bull. I haven't retrained my brain yet to treat immediately,  instead of playing that waiting game in my head.

Hi GinaB, Bob,

It's hard to get the jump on an attack when asleep, for sure. I know Goadsby and others advise that speed is of the essence when getting a triptan into you and I agree.

But they go one step further and say that once a CH attack has started, a triptan will not work. For me this is complete crap and GSK's literature confirms this. At any point during CH attack, first preliminary signs, right through to full blown 1+ hour(s) in, Sumatriptan injection always works for me. It is a 100% effective magic bullet, if I use it.

From the manufacturer (GSK) Imigran injection datasheet:


Quote:

When to use it: It is best to use your Imigran Mk II injection - (i) when the migraine headache or cluster headache begins; or (ii) when other symptoms of the migraine begin, such as nausea (feeling sick), vomiting or your eyes becoming sensitive to light. If you use Imigran Mk II injection later during the attack it will still work for you. Do not use your Imigran Mk II injection before the above symptoms occur.

Respectfully Bob, with regard to administration of Sumatriptan injection, I disagree with the notion of "delay and experience failure to get relief". So do the manufacturers and my specialist.

I know some CHers report this experience, but I think the idea that one can "miss" an opportunity to use Sumatriptan injection is false, especially for people like me who get the full 180+ minute attacks. CH seems once started, to be considered a freight train that cannot be stopped, I know for few triptan users, this is the case. Perhaps they should select a different triptan or ergot-alkaloid. In my experience, for the most part Sumatriptan injection will assist dramatically, even after awakening with CH attack in full flight.

Many of the patients I've assisted here in Oz echo that sentiment, even validating the extensive use of selected oral Triptans in their individual cases. Oral triptans are yet another example of a technique deemed invalid in CH by Goadsby and his cohorts.

Similarly, with 35 years practice I can lay down and writhe in a dark room, no longer resorting to pounding my head against a wall, but Goadsby and co would have us believe that "pacing the room", "bashing head against the wall" are in fact, necessary differential diagnostic criteria for CH and that in their absence, our collective CH diagnoses should be called into question.
This is wrong.

It would be fair to point out that Goadsby and co have neither had a CH attack, nor used a Triptan.

(Before I again get the links to Headache Specialists and "Cluster-like" headache - I should point out that my CH diagnosis is solid, textbook CH and 35 years consistent, "confirmed" by 8 years as a patient of a leading headache researcher)

Before the Vitamin D3 regimen, I for many years, awoke with force 10 CH well in progress and hit it with 6mg Imigran injection. There is nothing else I could have done. I had trialled 70 drugs that failed and I'm not going to take Imigran tablets "before bed" as a preventive, that's bad practice and bad medical advice for long term use.

I'm very lucky here in Oz, I get 6-12 injections for $6 through a public teaching hospital, so I've never had to divide them. I feel guilty for having such privileged access here, I know how much everyone else here experiences the difficulties of obtaining injections. From the relative luxury of this position, it would seem to me that dividing injections is almost exclusively a product of the immense cost nearly everyone else faces around the world for these injections. I do agree, 4mg would get the job done.

My specialist says doses are selected at 6mg for good reason and not to divide them. 6mg IS a divided dose. Initial trials of the drug used 12mg in subjects, but increased side-effect profiles, with no more effective an outcome in it's intended purpose. As principal creator of Zolmitriptan, with particular expertise in both CH and specialist experience with this drug group, I defer to his expertise.

The time to Sumatriptan full plasma concentration and elimination half-life are very short, so divided dose or not, it is not going to "last" very long at all. It aborts an attack, I don't know why so many people expect triptans to then "hold off" an attack, they are not designed to do this, they never were - check the plasma graphs. Headaches can recur very soon after a 6mg s/c injection.


Quote:

Pharmacokinetics: Following subcutaneous injection, sumatriptan has a high mean bioavailability (96%) with peak serum concentrations occurring in 25 minutes. Average peak serum concentration after a 6 mg subcutaneous dose is 72 ng/mL. The elimination phase half-life is approximately 2 hours. After oral administration, sumatriptan is rapidly absorbed,  70% of maximum concentration occurring at 45 minutes.  After a 100 mg dose the mean Non-renal clearance accounts for about 80% of the total clearance. Sumatriptan is eliminated primarily by oxidative metabolism mediated by monoamine oxidase A. The major metabolite, the indole acetic acid analogue of sumatriptan, is mainly excreted in the urine, where it is present as a free acid and the glucuronide conjugate. It has no known 5HT1 or 5HT2  activity. Minor metabolites have not been identified. In a pilot study no significant differences were found in the pharmacokinetic parameters between elderly and young healthy volunteers.

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I realise this is a cost-prohibitive exercise for most, but it does point out how quickly Sumatriptan injection is eliminated from your body and blood stream, explaining the recurrence, return or commencement of new CH attacks.
From the manufacturer (GSK) Sumatriptan injection datasheet:


Quote:

If the first Imigran Mk II injection helps your migraine or cluster headache, but the headache/migraine comes back later, you may use another Imigran Mk II injection. You must wait at least one hour between using the first and second Imigran Mk II injection. Do not use more than 2 injections (2 x 6 mg) in any twenty-four hours.

Link to the data sheet, every Sumatriptan user should have one of these:

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Sumatriptan is eliminated from the body very quickly.
Users should be aware of this.

Some may think I am here to advocate Sumatriptan use.
I hate the vile drug and would not wish it on anyone.
Sometimes I endure CH attack, rather than use it and risk rebound and recurrence.

For the record, just this year, this is how much Imigran I have not had to use (and then some) since the D3 regimen became effective for me.
Seeking out any and all possible preventives, including the D3 regimen is worth consideration, when staring down the barrel of this, or endless CH attacks.

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Apologies for my disposition.
I've been re-visited and am waiting for D3 loading doses to kick in. I can't, nor would I offer up excuses here, you all know how it is.

Cheers, Ben.

I have found that Suma works (knock on wood) no matter how far in the attack I use it.  I also have an issue with headaches returning several hours after an injection, it has happened on 3mgs and with the full 6mg dose.  I chalk it up to the divisiveness of the beast, one thing I have learned suffering from this condition is while some things "can" be quite effective there really is no "magic" bullet and over time I have had mixed results with ALL treatments.

Hello Ben,

Maybe it's just me...probably so...but I find the" tone" of some of your posts speaks so loudly I cannot hear what you are saying...and that's a shame...

Best

Jon

If I may chime in,  I am no expert on imitrex however I, due to the cost and availability like many others have to stockpile in the off season my Trex. 

Insurance is only covering 8 6mg injections per month for me.  So to get around this my dr prescribes me different varieties. 

My current favorite method is to get 6mg vials and the associated syringes.  I can then dose it down to as little at 2 mg of solution which I find works nearly as quickly and just as effective for a full blown KIP 8+ CH.   

The vials are harder to find however.  I did end up last cycle finding them at my local hospitals pharmacy, I then, this cycle took the box to my local Wallgreens and they were then able to order them special for me. 

I have also injected older 6 mg auto injections into a used vial so that I can more easily extract the fluid with a syringe.  I find that this is easier and more accurate than disassembling an auto injector and using a q tip or something to dose half way whilst holding a needled vial in your arm. 

This also gives me room for more injections if needed and I feel as through I get less of a rebound.  Without exceeding the 12 mg limit.

That chemical is a terrible substance but it has ABSOLUTLY saved my life.  And that is no joke.   I know that I wouldn't be here today if not for it!

Just my two cents. 

Eric

I agree with most of what the others have said about Imitrex. It's meant to abort an attack and is out of your system quick. It will not prevent attacks hours later. It can cause rebounds. If you feel you must use it,  then use it at the first sign of an attack.

My advice: Try to find a way to prevent the need to use Imitrex in the first place.  ;)

I4B

PS. Splitting doses is not the greatest of ideas, although many of us have done it and some still do. Instead, try getting the Imitrex 6mg vials so you can draw up smaller amounts and eliminate the re-using of a syringe more than once. And ... I would not recommend injecting the stat doses into empty, used vials.

Imitrex4Breakfast wrote on Mar 26^th, 2014 at 1:47am:

My advice: Try to find a way to prevent the need to use Imitrex in the first place.  ;)

This!

The Imitrex has been a huge to me and my ch's. I have just started Botox and found it to offer a large amount of relief. I have had 3 treatments over the last 9 mos and it has allowed me to go long periods without headaches and even stockpile some Imitrex.

Though I do understand the risks involved regarding infection,  it was actually my Neuro who suggested injecting the auto injector into a vial and then using a clean new syringe to dose down from the vial. 

It is a good idea to clean the top with an alcohol swab before injecting. 

I prefer to dose down as I have found that I get the same results with a lower dose and fewer side effects including the drowsy fog it puts me in.   Also because it is so expensive and insurance only covers so much,  I am basically always rationing for the long haul. 

I would agree though,  there are risks involved with that method or the imitrex tip option. 

Honestly if chewing my arm off would stop the pain I would do it.  So the risk of a little infection is pretty low on my list of concerns. 

Again just my two cents. 

Thank you all for sharing. 

Eric

Thank you all for the replies.  I've been on Verapamil for about 5 years, with good results. I even went 2 years ha free! This particular cycle is in the 3rd month, much longer than any in my 12 years of dealing with CH. I'm brand new to the immitrex and I guess I was just expecting better results. Almost every time I use the immitrex whether its 1.5mg or 6mg the pain goes away quickly but always returns in a few hours.  Until recently I used zomig tablets, with relief taking 45 minutes typically. But then I was good to go until the next night. I just wish the immitrex would work that way too.  I think I'd rather suffer longer and know I'm safe for the rest of the day,  then to have multiple ha in a day. Thanks again.  :)

Splitting doses has never really worked for me. Chances are that the beast is back within the hour if I don't kill it with the full complement.

Years and years of attacks have taught me that, if you feel the beast is coming, it is coming, no matter what. Waiting to see whether it will turn into a 7 or a 9 before I inject is therefore pointless. If I am away from O2 and I feel the beast coming, I hit it hard with 6mg, right off the bat.

The deeper I press the needle to inject, the longer it takes to kick in, therefore my tip is to only apply very light pressure while injecting. Can save 2-3 minutes of pain.