Migraine Treatments

 

 

Commonly Used Acute Migraine Treatments

Preventive Treatments

 

Commonly Used Acute Migraine Treatments

 

Migraine is an episodic, unpredictable headache disorder that presents with disabling attacks. These migraine attacks can be successfully treated with acute medications. Some of these medications are available over the counter and are prescription medications. Acute medications fall into general classes of medicines including analgesics, ergotamines, and triptans.
 
Analgesics are considered nonspecific migraine medications as they work on pain systems in general, not just activated pain pathways involved in migraine. For example, if a patient has a sprained ankle and a migraine, an NSAID may help reduce the pain of both conditions. In contrast, triptans and ergotamines are more migraine-specific medications. This means they work on the pain pathways involved in migraine, but have no effect on other pain pathways such as those involved in a sprained ankle.
 
How can you tell you are taking the right medication for your migraine?
 
You can determine the success of your treatment by asking yourself the following questions:  
  1. Are you pain free in 2-4 hours?
  2. Are you functioning normally in 3-4 hours?
  3. Does your headache respond to treatment consistently at least 50 % of the time?
  4. Are you comfortable with taking the treatment prescribed and still able to plan your day?
If you answered “No” to one or more of these questions, your treatment should be reassessed.
You can determine the success of your medication by treating as few as two or three headaches and monitoring your improvement, or lack thereof. Comparing two similar headaches with similar results predicts the 3rd headache result with about 70% accuracy.
 
To avoid continued failure of a give medication, assess whether you wait too long to take your before treating your headache. Delay in treating your migraine can make it more difficult for your headache to respond to the medication. For many patients, there is a “window of opportunity” during a migraine where there is an increased chance that the headache will respond to treatment. This window of opportunity occurs within the first two hours following onset of headache pain. This is why physicians work with their migraine patients in teaching them to treat earlier in the course of the attack, and if possible, treat when pain is mild.
 
Two important considerations when managing migraine
  1. Make sure the headache is a migraine and
  2. Restrict your use of acute migraine treatment to no more than 9 days per month. If you find that you need more acute medication than 9 days per month, then migraine prevention therapy is likely needed.  

Analgesics & NSAIDs
 
  • Nonspecific pain medications
  • Readily available as over-the-counter remedies (including aspirin, naproxen sodium, ibuprofen, acetaminophen, among others)
  • Cost affordable
  • May be given as monotherapy or in combination with other agents (eg. acetaminophen, aspirin, and caffeine)
  • Should not be used in patients who have contraindications for using NSAIDs (hyperacidity syndromes such as ulcer, gastrointestinal esophageal reflux disease, the triad of aspirin sensitivity, nasal polyps, and asthma and kidney disease)
  • Regular or even daily use of these medications may make headaches worse due to medication overuse
Ergotamine,
Ergot Combinations
Ergot Alkaloids (Dihydroergotamine)
 
  • There are currently several different formulations of ergotamine for the acute treatment of migraine including oral, rectal, or intranasal
  • Dihydroergotamine is available as an intranasal, intramuscular, or intravenous treatment
  • May work on more than just activated pathways in migraine
  • Nausea may be a side effect from these medications and also may be part of the migraine itself. Some patients may benefit in taking these agents with another medication to prevent nausea. 
Triptans
  • Readily available with prescription
  • Seven different triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan)
  • Available as oral tablets, orally disintegrating tablets, nasal sprays and subcutaneous injection, so you may request a specific formulation if you have a preference.
  • More migraine specific
  • Some patients may find improved response to triptans if they take their medication early in the course of the attack when pain is mild.
  • Common triptan side effects may include tingling, sleepiness, flushing, throat or chest tightness
 

 

 

>Preventive Treatments

What are they?
 
Preventive medications are taken daily to prevent migraine attacks from occurring. They are not intended for use to treat an acute attack. Many different preventive medications are available, and the choice of medication depends on many factors such as co-existing conditions including high blood pressure, asthma, diabetes, or pregnancy (among others). Therefore, choosing medications for preventive therapy can be a complex process. Before starting to take medications, several basic principles need to be considered:
  1. The choice of a preventive medication needs to be tailored to meet each person's individual needs.
  2. Co-existing medical conditions (such as depression, obesity, anxiety, among others), drug side effects, other medications being taken, and individual patient needs will help determine which medication a physician chooses.
Do you need migraine prevention?
Migraine patients do not want to suffer from an attack, so prevention is important, even if they suffer from only one attack a year. Those who suffer from frequent attacks will need more aggressive prevention strategies that sometimes include medication. This decision is made by discussing treatment and management options with your physician. Additionally, nonpharmacological prevention may help if you have:
  1. Disabling attacks despite appropriate acute treatment
  2. Frequent attacks (>1 per week)
  3. Insufficient or no response to acute drug treatment
  4. Poor tolerance or contraindications for specific acute pharmacological treatments
  5. History of long-term, frequent, or excessive use of pain medications (analgesics) or acute medications that make headaches worse (or lead to decreased responsiveness to other drug therapies)
  6. Patient preference
Goals of Preventive Therapy
Migraine prevention is intended to reduce the frequency, suffering and disability associated with migraine attacks. Unfortunately, preventive treatment strategies rarely eliminate migraine, but they can reduce the frequency and severity of attacks. The ultimate goals of migraine preventive therapy are to:
  1. Reduce frequency, severity, and duration of attacks
  2. Improve responsiveness to treatment of acute attacks
  3. Reduce level of disability
  4. Maintain cost of care for migraine treatments
  5. Reduce excessive or overuse of acute medications
Which Treatment is right for you?
When deciding on preventive therapies, it is important to review with your doctor several important management principles:
  • Ask your physician what you can expect from the medication regarding its efficacy. In other words, as “What is the benefit likely to be for me when I take this medication?”
  • Low doses are used at first and gradually increased to higher doses as needed. Therefore, you may need to increase medication dose until the desired response is achieved.
  • Lower dosing frequency is often convenient; however, some medications may need to be taken twice or even three or four times a day. Discuss the dosing frequency of the medications and make sure it is a plan that is convenient and easy to follow. Otherwise, you may not take the medication as prescribed and the efficacy benefits may not be achieved.
  • It may take 2 to 3 months before you notice a decrease in the frequency or severity of attacks even after reaching “the beneficial dose”.
  • Treatment may be required for 6 to 12 months or longer.
  • All medications have potential side effects so any unusual symptoms should be reported to your physician. It is important to discuss potential side effects and how they may be avoided or treated if they appear. Different medications have different safety and costs factors and these may play a factor in deciding which medication is right for you.  
  • Side effects can often be limited by using low doses, increasing the dose slowly, or allowing time to adjust to the medication. If you are not tolerating the medication and if you start to have side effects, contact your doctor to discuss changes to the treatment plan.
  • You should not suddenly stop taking preventive medications because of the risk of rebound headache or other side effects. Preventive medications need to be gradually tapered off after a period of sustained benefit.
  • Discuss any other possible health condition that may have an influence on your headaches including depression, hypertension, seizures, diabetes, menopause, anxiety, and asthma, among others. These illnesses may play an important role in deciding causes of your headaches and choosing treatment.
  • Preventive drugs can be used in a variety of different dosing strategies such monotherapy or polytherapy (several different medications) as:
    1. One drug titrated to the ideal dose (monotherapy)
    2. Two drugs typically from different drug classes used to less than maximal dose but used to complement each other and reduce the risk of side effects associated with each of the medications given in high doses
    3. One drug switched for another drug in order to improve tolerance or efficacy
    4. Three or more drugs in either maximal or submaximal doses typically added one after another due to inadequate response. Your preferences can strongly influence the selection of this process This is much like a trial and error process and may take a while before treatment success is identified and the desired efficacy is achieved
Adding different medications may be a preferred treatment strategy as many patients have migraine in addition to another condition that is commonly associated with migraine such as depression, anxiety or obesity. Recognizing that there may be several medical concerns is the first step in making sure each condition is treated optimally. Sometimes this is achieved with monotherapy, but often this may require polytherapy.
 
Commonly used preventive medications

 Type of medication
Medication class
Generic name
Side effects
Blood pressure medications
 
Beta-Blockers
Atenolol
Metoprolol
Nadolol
Propranolol
Timolol
 
Fatigue
Depression
Nausea
Insomnia
Dizziness
Calcium channel blockers
Verapamil
Diltiazem
Nimodipine
Weight gain
Constipation
Dizziness
Low blood pressure
Antidepressants
 
Tricyclic antidepressants
Amitriptyline
Nortriptyline
Imipramine
Weight gain
Dry mouth
Sedation
Decreased libido (sex drive)
 
Selective Serotonin Reuptake Inhibitors (SSRI/SSNRI)
Fluoxetine
Paroxetine
Sertraline
Weight gain or loss
Decreased libido
Anticonvulsants
 
Divalproex sodium
Gabapentin
Topiramate
Weight gain or loss
Sedation
Skin rash
Serotonin antagonists
 
Methysergide
Methylergonovine
Blood vessel spasm
Abdominal scarring (very rare)
Unconventional treatments
Magnesium salts
Magnesium oxide, magnesium diglycinate, magnesium chloride slow release
Diarrhea
Vitamins
Riboflavin
Urine discoloration
Herbals
Mig-99 (Feverfew), Petasites
Burping, GI
 
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