Warning - long post, complex topic.
My wife suffers from severe migraines and possibly cluster headaches. She sees a neurologist. I am very involved in her healthcare because she has multiple severe illnesses. She went through a lot of medicines to find what works for her. She also has stage IV endometriosis with complications of the GI tract. So, this list may seem extensive, but her migraines (and other illnesses) are rather severe; this is not all of her meds by a long shot, only those specifically prescribed for migraine treatment.
She too gets no relief from the triptan class and has tried all of them; she hasn't tried ergotamine tartare though... being that it's a precursor to LSD it is controlled in the US... bastards.
She and her neurologist worked out the following regimen:
•Aimovig once a month injection (this was the biggest player and really works for her)
•Metoclopramide (reglan) 10mg. This medicine is a DA antagonist (think antipsychotics) plus 5ht3 antagonist (like ondansetron). Used PRN for nausea/vomiting and pain
•Ondansetron used PRN for nausea/vomiting
•Butalbital/acetaminophen/caffeine used PRN for breakthrough migraine/pain (butalbital is a barbiturate and schedule III medicine; the addition of codeine makes it schedule II in the US). Using this drug makes more sense for migraines than hydrocodone imo. Also, it is designed to be prescribed for migraines so a doc may feel more inclined to provide; however, its use is rather discouraged currently given its abuse potential. It is scheduled III in US and I'll tell you it is certainly abusable; I love it! Opioids (re hydrocodone) really aren't the best treatment for migraines (and it's hard for me to say that cuz opioids are my DOC). However, you stated caffeine makes your migraines worse so this may not be a good choice. I'm sure there's a butalbital preparation w/o caffeine but it's likely harder to obtain given the abuse potential and general lack of use of barbiturates in medicine these days. Wiki lists a formulation called "Cafergot PB" containing ergotamine tartare, caffeine, butalbital, and belladonna alkaloids. Damn that sounds awesome!!
•Ketorolac - a stronger Rx NSAID (like ibuprofen but much stronger) used PRN.
On really bad days we will go to our PCP to get an IM injection of this. I've asked for a take home IM kit but no luck yet.
•Methylprednisolone pack for acute care to break multiple day migraine cycle (we've yet to have to use this one) to be used PRN.
I have heard stories of people having success with single recreational dosing of tryptamines (LSD, psilocybin, DMT) or daily microdosing of the same though she hasn't tried this. I will say that when we have taken LSD (which we used to A LOT) she would be headache and migraine free for about a month following a 100+ug dose. This is interesting because she gets no relief from triptan medications that are structurally very similar; but triptans are really only worth taking to prevent a migraine at its onset, not to be taken mid migraine. If taken mid migraine triptans are absolutely useless.
When her migraines reach an emergency level of pain we proceed to the ED (Emergency Department). She is allergic to antihistamines so cannot have the "migraine cocktail" so often used in the ED containing diphenhydramine, ondansetron, and ketorolac (I believe?). She typically ends up with an IV of hydromorphone (dilaudid) and ondansetron to break the pain cycle; again, this is in the ED only. I wish we had an IV hydromorphone kit at home but she would likely end up with no medicine and I would likely end up dead.
I'll add to my post if I remember anything else. Good luck. I suggest keeping an open mind to medication options outside of opioids and sedatives (barbs, benzos, mscl relaxants etc); again, I love these drugs but have to admit there is some real evidence pointing toward the use of other agents for migraine treatment. We can't offer specific medical advice here, but can and do share our experiences, knowledge, and at times, our opinions.
Do you have any idea what is causing your migraines? That's a good place to start in the search for treatment.
i have deep emotions of acceptance and possible endurance.