Today I wanted to talk to you about the various treatment strategies for migraine. But first, what exactly is a migraine and how does one get diagnosed with this?
What is a Migraine?
A migraine is a type of headache that is recurrent and usually moderately or severely painful. Did you know that diagnosis of migraine is a clinical diagnosis? This means that you can be diagnosed with migraine just based off of your symptoms, and you do not need any fancy tests to diagnose this. Although many people will undergo a screening imaging test such as a CT scan or MRI for new onset migraine, this is to rule out underlying defects such as a brain mass or genetic variant, and not to diagnose migraine.
A migraine can be diagnosed by a history of 5 or more headaches lasting 4-72 hours, severe enough to limit your usual daily activity and be accompanied by nausea or light or sound sensitivity. Although frequently migraines are described as throbbing, occurring on one side of the head, associated with vomiting or sometimes an “aura” of symptoms preceding the migraine pain, none of these symptoms are required in the diagnosis of migraine and are not necessarily found in everyone.
For a long time it was not clearly understood what caused migraine. Today, researchers feel more confidant that it is secondary to hypersensitive brain cells. Various environmental, chemical or physical stressors will trigger these sensitive cells to fire and trigger neighboring brain cells, leading to a cascade of migraine pain.
Ok, so I have been diagnosed with Migraine. What can I do about it?
Unfortunately, there is no cure for migraine. But there are a variety of treatment strategies that can help to control your symptoms. For some of you, this may be old news. For others, you may be new to headaches or recently diagnosed with migraine and you may not understand what your treatment options are. So let’s start with the basics.
Abortive (Acute Pain) Treatment
For many people, migraines thankfully only come once in a while. If you are having no more than 2-3 migraines per month, having an appropriate and effective abortive therapy may be all you need.
Ibuprofen and excedrin are very good initial abortive treatments. A fairly large dose of ibuprofen, approximately 600mg to 800mg, taken immediately at the onset of migraine is an effective initial treatment. Don’t wait too long to take your medication, as the migraine is easier to abort before it reaches more severe intensity. I have never seen Tylenol be that effective and I would only suggest this as a first line therapy if you have an allergy or medical condition that prevents you from taking ibuprofen or other NSAIDS.
When excedrin or ibuprofen fail to control your symptoms, you need a prescription abortive pill. These most commonly fall into the class of medications called triptans. Sumatriptan is the first generation triptan and therefore the cheapest. Most insurance plans will require you to try this one first before they allow you try some of the other ones. Many people will have to try more than one triptan to find one that works for them. This class of medications tend to be somewhat expensive and most insurance companies will limit you to 6-9 of these per month.
Another abortive medication is called fiorinal (butalbital/acetaminophen/caffeine) or fioricet (butalbital/aspirin/caffeine). The main difference between the two, is one has acetaminophen (Tylenol) added to it and the other one has aspirin. These medications work reasonably well for some people and a bonus, they are cheap. The drawback is that butalbital falls into the class of drugs called a barbiturate. Barbiturates were more commonly used in the 1960’s for disorders such as seizures and anxiety. However, they do have some addictive properties and it is likely for this reason that they have fallen out of favor.
Preventative ( Prophylactic) Medication:
What if I need more than the 6 tabs of abortive pills every month? Then you may be in need of a preventative medication. When people are experiencing more than about 1 migraine per week, or if they cannot control the severity of their migraine with abortive medications, then prophylactic treatment might be needed.
A prophylactic medication is one that is taken daily to prevent the onset of migraine. There are numerous different classes of medications used for this.
– There are several different classes of antidepressants used with varying levels of migraine control. One of the first drugs used was amitriptyline (elavil), a tricyclic antidepressant. There are also SSRI’s (Selective Serotonin Reuptake Inhibitors) like prozac, zoloft and lexapro, and SNRI’s (Serotonin- Norepinephrine Reuptake Inhibitors) such as Effexor. Most of the antidepressants work by increasing or blocking reabsorption of important “feel good” neurotransmitters such as serotonin and norepinephrine.
This class of medications works reasonably well for migraines for some people, but do have considerable side effects which may limit your ability to tolerate them. You should try at least 3 different medications from this class before assuming none of them work for you as they all have different positive and negative effects.
– Beta blockers are most commonly known as heart medications. They block the effects of the hormone adrenaline which can make your heart beat slower. The fact that they seemed to reduce migraine symptoms significantly in trials of cardiac patients was a nice coincidence, but the mechanism is not fully understood and may be related to prevention of arterial dilation. Propranolol is the most commonly used one.
Beta blockers can be very effective at reducing migraine and are relatively inexpensive. They also can lead to multiple side effects including too slow of heart beat, fatigue, insomnia and paradoxical racing heart beat. These should be weaned off slowly once initiated.
Calcium Channel Blockers
– A class of medications primarily used for cardiac conditions and high blood pressure that have been show to reduce the incidence of migraine. These are not often used for migraine prevention due to several adverse side effects but verapamil is the most commonly used one.
Anti Seizure Medications
– Topiramate and depakote are the most commonly used for migraine prevention and can be quite effective, but like most medications also have the potential for a number of unpleasing side effects. These are typically avoided in women of child bearing age or who are actively seeking to become pregnant.
– This is the newest class of drugs for prevention of migraine. These are actually the first and only medications that were actually designed specifically for the prevention of migraine. CGRP is a small protein that is present in high quantities in the sensory nerves of the head and neck. These medications use monoclonal antibodies to target either the CGRP protein or its receptor. They require once monthly injections and hold some promise for people with severe refractory migraine whom other prophylactic medications have not worked.
The main drawbacks seem to be that they are injections, sometimes having to be performed in a doctors office, and they are extremely expensive. There have been cases reported of worsening of migraine symptoms, and you must wait 1-3 months for side effects to wear off since it is injected. There also have been people with severe migraines refractory to other medication intervention that these have worked very well for. You can discuss whether you are a good candidate for these with your doctor.
I hope this has helped to clarify some of the initial treatment strategies for controlling migraine. Discuss them with your medical doctor to find a strategy that works for you.
If you live in the Southern California area, be sure to check me out at DrCamilleMD.com. We are open during COVID, and we make house calls to keep you out of the ER.
Dr. Camille, MD
The Migraine Doctor