HeadWise HeadWise: Volume 5, Issue 1 | Page 17

Considering the history of these beta blockers , two ophthalmologists – John Hagen and Carl Migliazzo – recently made a startling observation . During a game of golf , these ophthalmologists had an “ eureka ” moment while discussing possible treatment options for Dr . Hagen ’ s daughters who experience migraine . They observed that some of their patients treated for glaucoma with timolol eye drops reported that if the timolol eye drops were instilled during a migraine , the headache would be rapidly terminated .
Following their discussion on the use of beta blocker eye drops for the treatment of acute migraine , Drs . Hagen and Migliazzo reported on a series of seven patients who had successfully treated acute attacks of migraine with timolol eye drops , which was published in The Journal of the Missouri State Medical Association in 2014 . The seven patients in these case reports were all female , ages 38 to 76 , who presented with migraine syndromes , with and without aura . Five of the seven patients reported complete pain relief , with one patient reporting complete pain relief within 10 minutes of treatment . The two remaining patients reported pain relief of 8 and 9.5 on a 1 to 10 scale , with 10 representing complete relief . These patients were all instructed to use 1 or 2 drops of their beta blocker eye drops as early as possible during their acute migraine attacks . Patients were advised to blink several times to encourage the eye drop to pass into the lacrimal drainage duct . Interestingly , one patient used timolol drops sublingually and reported receiving pain relief . The eye drops were generally well-tolerated with only one reported side effect of shortness of breath which only occurred if eye drops were used in both eyes . Drs . Hagen and Migliazzo stress all patients underwent a complete medical history and ophthalmic examination prior to the initiation of topical beta blockers . Patients were advised to read the package insert and inform their primary care physicians of their acute use of beta blocker eye drops .
Since the publication of these case reports , Drs . Hagen and Migliazzo have received multiple messages and phone calls from fellow physicians who have reported success with patients using beta blocker eyes drops for migraine relief . Although these represent only a few case reports , they provide additional evidence of the use of topical beta blockers in acute migraine , and the treatment appears to be well-tolerated . The physicians are hopeful to see the development of wellcontrolled studies to validate the efficacy of beta blocker eye drops for acute migraine relief .
How Would Beta Blockers Work in Acute Treatment of Migraine ? The exact mechanism of beta blockers in the treatment or prevention of migraine is unknown . Beta blockers work primarily by blocking the stimulating or activating effects of adrenalin . Considering that individuals with migraine have inherited a nervous system that is more excitable than those without migraine , it is easy to assume that beta blockers may in some way reduce this inherent excitability . In other words , the beta blockers may make the nervous system less vulnerable to migraine . While this likely explains the migraine prevention benefits , it also may provide a rationale for their use in the acute treatment of migraine headaches .
One can imagine that during a migraine , the threshold for nervous system activation has already been surpassed and hence the process of migraine occurs . Beta blocker eye drops enter the nasal cavity through the lacrimal duct ( a small passageway from the eye to the nose that drains tears from the eye ) very quickly . Once in the nose , the eye drops are rapidly absorbed into the blood . Conceivably , they could block the activating effects of adrenaline and allow the nervous system to reverse migraine . Beyond the speed of entry into the blood , another major advantage of nasal absorption is that medications do not have to pass through the liver before entering the systemic circulation , thus avoiding their metabolism by the liver and allowing a much smaller dose of medication to be effective . Beta blockers have also been found to reduce the electrical excitability of nerve cells , and this too may be part of their potential mechanism .
When oral preparations of beta blockers are used to prevent migraine , levels build up slowly in the blood . This action works well for prevention but during migraine , these levels would increase too slowly to be effective . Using an eye drop with rapid absorption through the nose circumvents that problem . Also , nerves in the nasal cavity may become activated and potentially , beta blockers could act directly on these nerves . Finally , it is possible that some of the beta blocker eye drop could be absorbed into the brain and exert their beneficial effect in that manner .
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