FAQ Episode 34: A visual aid for migraine relief
FAQ Episode 34: A visual aid for migraine relief
Frequently Asked Questions for Natural Migraine Relief
The Natural Migraine Relief blog focuses on applying individualized non-drug solutions to address the root causes of migraine headaches. Once in a while I share a lesser known drug application that is worth passing along, and this is one of those occasions.
The repurposed use of a common migraine medication
For decades, the drug class called beta blockers has been used to manage migraines, usually taken orally on a daily preventive basis for episodic (four or less/month) headaches. The beta blocker mechanisms of action providing this benefit include:
Alowing blood vessel relaxation
Blockading the brain change called “cortical spreading depression” that is part of initiating a migraine.
Modulating the levels of neurotransmitters, primarily serotonin
Blocking pain signals
While the beta blocker family is most commonly used for treating high blood pressure, there are two beta blocker medications that have been FDA approved far daily migraine prevention, one of which is timolol. Timolol is also used as an eye drop to manage glaucoma by lowering intraocular pressures. Somewhere in the 2000s it was noted that the timolol eye drops used for reducing eye pressure also helped with acute migraines. Eureka! Another example of an “interesting coincidence” that becomes the potential parent of an useful advance in medical therapy.
The case of how eye drops might provide migraine relief makes sense on several levels:
when eye drops drain from the eye, they exit via the tear ducts, then across the nasal passages on their way down the back of the pharynx. Who hasn’t eventually tasted a drop of medicine they put in their eye?
the trigeminal nerve endings in the nasal area, particularly the sphenopalatine gangion (SPG) branch of the maxillary trigeminal are known to be the mediatiors of signals that often precipitate migraine headaches.
if timolol could directly affect the area of trigeminal nerve and the SPG, it could blunt an emerging migraine headache.
What the reasearch says about nasal timolol for acute migraines
Here’s some data from three of several well done research articles:
A JAMA Opthalmology journal study1 showed that 82% of patients cleared their migraine pain within 20 minutes of timolol use
A JAMA Neurology journal study2 found that timolol therapy was twice as effective as placebo therapy for clearing migraine pain acutely.
A Missouri Medicine case series3 published January 2024 found that 2/3 of patients responded well to intranasal timolol. The compounding pharmacy they recommended in that study was O’Brien Pharmacy in Mission, KS (913) 322-0001. They used a 0.05% timolol solution with Mucolox, to enhance nasal absorption. Each 0.1 mg spray delivered 0.5 mg timolol, given as one spray in each nostril as early in the headache process as possible. One other set of sprays could be used 15 minutes later, if required. No more than these 4 sprays as described above were to be used per 24 hours.
Who might want to use this medication and route of therapy?
Currently there are several drugs for acute therapy of migraine, including the triptan and CGRP blocker families. If you are using one of these meds and:
have significant and persisting associated side effects
find that they are too expensive, either off insurance or even with co-pay
have found that the migraine blocking benefit is equivocal or incomplete
you may want to give intranasal timolol therapy a try.
It has been advised NOT to use the nasal timolol if you are already on an oral daily beta blocker prescription.
Keep in mind that the routine advice about potential adverse effects of timolol use or overuse could also apply to intranasal use, including:
short term change in visual acuity
dizziness or nausea
slow or irreular heart beat
worsening of underlying asthma
headache
lower extremity swelling
Considerations for a trial of Timolol for acute migraine
You will need three things to give this preventive therapy a trial:
A physician willing to write your prescription, and to call it to a compounding pharmacy.
A compounding pharmacy that can make this up in a nasal spray. See the comments above in the third referenced case study, Many compounding pharmacies can mail this medication to you out of state, if necessary. Start by searching online for “find compounding pharmacy near me”
Use the medication as prescribed (again, as reviewed in the third referenced case study report) as soon as one senses a headache coming on.
As you probably know, I prefer to manage the root causes of migraine first before drug therapy, but when you have acute migraines that are not responding to or breaking through what you’re currently doing, you need front line therapy options right now. I’ve found this therapy to fill an useful acute care niche for some of my migraine patients. Ask your doctor whether its right for you.
This research summary is provided as a free informational service. Please use prescribed medications under the supervision and according to the individualized instructions of your personal physician.
Short-term Efficacy and Safety of Topical β-Blockers (Timolol Maleate Ophthalmic Solution, 0.5%) in Acute MigraineA Randomized Crossover Trial Abraham Kurian, MS, DO et. al. JAMA Ophthalmol. 2020;138(11):1160-1166. doi:10.1001/jamaophthalmol.2020.3676 https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2771168
Timolol Eyedrops in the Treatment of Acute Migraine Attacks: A Randomized Crossover Study Matthew Cossack, MD et. al. JAMA Neurol. 2018;75(8):1024-1025. doi:10.1001/jamaneurol.2018.0970 https://jamanetwork.com/journals/jamaneurology/fullarticle/2680666
Nasally Delivered 0.5% Timolol Beta Blocker Sucdessfully treats Acute Migraines in a Referral Heqadache Clinic: A Case Series. Missouri Medicine Stephen Kosa H.D et.al. Jan/Feb 2024 Vol. 120 #1 pp. 33-36 https://digitaleditions.walsworth.com/publication/?m=11307&i=815984&p=2&ver=html5