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Living with Your Migraines: Tips for Treatment and Prevention

What is a Migraine Headache?

A migraine headache is a common neurological disorder that may affect 10 to 15 percent of the population. In the U.S., more than 30 million people suffer from migraines, and over 5 million have at least one migraine attack per month. You might experience debilitating throbbing pain around the eyes and temples lasting for hours, nausea and vomiting, and a greater sensitivity to light and sound. Migraines tend to occur between 20 and 50 years of age, and are three times more common in women than men, possibly due to estrogen fluctuations. The frequency of migraine attacks may vary from a couple of times per year up to multiple times per month.

How Do Migraines Impact Your Quality of Life?

Over ninety percent of people are not able to carry on their normal daily routine, whether it be work, school or parenting, when they experience a migraine. In addition, migraines tend to affect people in their working years. It is estimated that roughly $13 billion is lost in work productivity each year due to the impact of migraines.

Medical costs due to the diagnosis and treatment of migraines surpasses $2 billion annually, and the World Health Organization ranks migraine as 19th highest disease to cause disability worldwide.

How Can I Tell if I Have a Migraine?

Over two-thirds of people that suffer from migraines are women who have a family history of the disorder. Almost half of all people who have symptoms that meet the guidelines for diagnosis of a migraine instead thought they had a tension headache, sinus headache or another type of headache. Tension headaches often occur on both sides of the forehead. Common symptoms that occur during a migraine include:
  • Throbbing pain
  • Light and sound sensitivity
  • Nausea and/or vomiting
  • Pain on only one side of the head
  • Vision changes or blurred vision
  • Aura

Is There a Cure for Migraines?

There is not a cure for migraines yet, but major advances have been made in drug treatments over the last two decades. Serotonin (5-HT), a neurotransmitter, is a key player in the mechanism of how a migraine occurs. Selective serotonin 5-HT1-receptor agonists (triptans) have been developed and are a mainstay in the treatment of acute migraine headaches. Sumatriptan (Imitrex) was the first triptan developed by Glaxo in 1992. Several other triptans have been developed since Imitrex, including eletriptan (Relpax), frovatriptan (Frova), and zolmitriptan (Zomig).

What is An Aura?

About 20 percent of migraine attacks are preceded by neurological symptoms (aura) that lasts roughly 10 to 30 minutes. An aura may start as much as 24 hours before the migraine pain and may manifest as sensitivity to light (photophobia), sensitivity to sounds (phonophobia), dizziness, a ringing in the ears, blurred vision, seeing lines or bright lights, confusion or vertigo (dizziness). An aura may also occur during the headache or even without a headache.

About 80 percent of migraine headaches are not preceded by an aura, but involve vague symptoms such as mental clouding, mood swings, and fatigue.

What Might Trigger a Migraine Headache?

Many different events might trigger a migraine -- food, emotional stress, dehydration or hormone changes can bring on an attack. Flashing lights or reflections, exhaustion, skipping meals, or an excess of sugar can also lead to an attack in some migraineurs. Certain foods or additives, such as MSG, red wine, aged cheeses or meats may be the culprit.

It is important for each person to keep a journal and try to identify any specific event or food that repeatedly precipitates their migraine attack so they can work to eliminate this trigger from their daily routine.

How Is a Migraine Diagnosed?

Your doctor will evaluate your history and symptoms to determine if your headaches are migraine headaches. Usually no special tests are required. He or she will ask if you experience an aura with your headaches, and if your headache is localized to one side of your head or both. You might be questioned about the occurrence of a "migraine hangover" - a 1-2 day phase after the attack defined by fatigue and irritability. If there is any doubt about your diagnosis, your doctor may suggest you see a neurologist, a medical doctor with expertise in illnesses of the nerves and brain.

Migraine Treatments: What are the Options?

Migraine medications fall into two categories: Pain-relieving drugs can be taken early at the onset of the migraine (called abortive drugs) and includes agents in drug classes such as NSAIDs, triptans, or ergots. Alternatively, medications can be taken every day to reduce migraine attacks (called preventive drugs) and includes drug classes like certain beta blockers, calcium channel blockers, anticonvulsants or antidepressants. It might take 3 to 4 weeks to reach the full effect of preventive therapy. Treatment depends upon the frequency, severity, and daily impact of your migraines; previous treatments and costs will also be considered.

Acute Migraine Treatments: OTCs

Mild migraine headaches can be treated with over-the-counter (OTC) pain relievers such as acetaminophen (Tylenol), or nonsteroidal antiinflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin IB) or naproxen (Aleve). Caffeine may augment the effects of other pain relievers in products like Anacin (aspirin/caffeine) or Excedrin Migraine (aspirin/acetaminophen/caffeine). If you have a history of stomach ulcers or bleeding, NSAIDs or aspirin should not be used. OTCs are best used early in the migraine. Higher doses or prescription NSAIDs may be needed for moderately severe migraines - ask your doctor.

Acute Migraine Treatments: Triptans

Serotonin 5-HT receptor agonists (triptans) are also used early in the severe migraine for abortive treatment. Their use is preferred over habit-forming narcotics, such as butalbital. Dosing options include tablets, injections and nasal sprays. These agents act to constrict blood vessels and block pain messages in the brain.

Triptans are very effective, but should not be used in patients at risk for a heart attack or stroke. Prescription medications in this class include almotriptan (Axert), eletriptan (Relpax), frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt), sumatriptan (Imitrex), and zolmitriptan (Zomig).

Acute Migraine Treatments: Ergots

Medications called ergotamines are also used to stop the development of a migraine (abortive agent), and include treatments such as sublingual ergotamine/caffeine (Cafergot) and dihydroergotamine (D.H.E. 45, Migranal Spray). Ergot agents have activity at serotonin receptors involved in migraine attacks. Most experts consider triptans a better option over ergots for severe migraines due to better effectiveness and reduced side effects. Ergot side effects may include nausea, vomiting, dizziness and medication-overuse headaches. Pregnant women and patients with high blood pressure, heart disease, or kidney or liver disease should not use ergots.

Preventive Migraine Treatments: Tricyclic Antidepressants

Tricyclic antidepressants (TCAs) like amitriptyline have been used for many years to treat migraine, but are not FDA-approved for this use. Like many other treatments in migraine, they seem to work by blocking the reuptake of neurotransmitters such as serotonin.

Other TCAs used in migraine prevention, but with less data than amitriptyline on effectiveness, include doxepin and nortriptyline. Side effects like drowsiness and dry mouth are common with TCAs; starting treatment with low doses and taking at bedtime may help. All of these options are available generically and cost-effective for most patients.

Preventive Migraine Treatments: Beta-Blockers

You might be a candidate for preventive treatment if you have several severe migraines per month, if other treatments don't work, or if your migraines last 12 hours or longer. Certain cardiovascular (heart) drugs work well for prevention of migraines - one class is called the beta-blockers. These drugs are often prescribed to treat high blood pressure, but they work well in about half of the people who take them to prevent migraines. Beta-blockers act to relax blood vessels but how they work to prevent migraines is not fully understood. Examples of affordable generic beta-blockers include propranolol, timolol, and atenolol.

Preventive Migraine Treatments: Calcium Channel Blockers

Like beta blockers, calcium channel blockers (CCBs) are used for high blood pressure as well as migraine prevention. CCBs might be especially useful for patients with aura. Verapamil (Calan, Verelan) is often selected as the first CCB for migraine because it has fewer side effects and is available in an affordable generic form. Like beta blockers, the exact way that CCBs work to relieve migraines is not known, but they appear to reduce narrowing of blood vessels. Side effects with CCBs, such as dizziness, drowsiness, constipation, low blood pressure or headache, may occur - but these may lessen over time.

Preventive Migraine Treatments: Anti-Seizure Medications

Certain anti-seizure medications (anticonvulsants), for example, valproic acid (Depakene) or topiramate (Topamax), have been shown to be useful for migraine prevention. However, these drugs can be associated with unpleasant side effects at higher doses. Valproic acid may lead to nausea, vomiting, weight gain or hair loss (alopecia). Valproic acid should not be used in pregnancy. Topiramate may cause a sensation of tingling, burning (parethesias), drowsiness, nausea, weight loss and dizziness. Anti-seizure medications should be slowly tapered if it is decide to stop treatment. Patients should discuss side effects with their doctors prior to treatment.

Preventive Migraine Treatments: Botox

OnabotulinumtoxinA (Botox) may be an option for those who have had limited success with more traditional treatments. Botox is FDA-approved to help prevent migraine headaches in adults with chronic migraine, defined as 15 or more headache days a month, each lasting 4 hours or more.

In the doctors office, multiple Botox injections are made into the muscles of the forehead and neck, and treatment is repeated every 12 weeks if successful. However, there are maximum dose limits to be aware of when Botox is used for other indications, such as to smooth wrinkles or for overactive bladder.

Migraine Agents for Nausea and Vomiting

Nausea and vomiting often accompanies migraine headaches. In fact, nausea is reported by 73 percent of migraineurs and vomiting by 29 percent.

Medications for nausea and vomiting can usually be used at the same time as medications used to treat the migraine. Traditional agents for nausea and vomiting include metoclopromide (Reglan, Metozolv), prochlorperazine, or promethazine (Phenergan). Metozolv is an orally dissolvable tablet, and prochloperazine and promethazine are available as rectal suppositories, which may be preferred over oral agents if nausea or vomiting is present.

Other Headache Types: Vestibular Migraines

Take a regular, throbbing migraine, throw in a component of vertigo (a sensation of motion or spinning) and what you get is a vestibular migraine, a rare form of a migraine headache. The dizziness actually stands out as the most prominent feature of a vestibular migraine.

Triptans or antiinflammatory medications are used in acute attacks; calcium channel blockers, selective serotonin reuptake inhibitors, and anti-seizure medications may also used to treat frequent vestibular migraines. Famed pop singer Janet Jackson suffers from this uncommon type of migraine.

Other Headache Types: Menstrual Migraines

The menstrual cycle and hormonal changes may be linked to a migraine attack in some women called a "menstrual migraine." Oral contraceptives and hormone replacement therapies may aggravate migraines in some women; in other women oral contraceptives may relieve migraines. Migraines associated with the menstrual cycle tend to start a few days before or during the period.

In general, menstrual migraines tend to be more severe, last longer and occur more frequently than migraines that occur at other times. Menstrual migraines respond well to NSAIDs and/or triptans.

A Word of Caution: Migraines in Pregnancy

Roughly 55 to 90 percent of women report an improvement in their migraines during pregnancy, probably due to stablization of estrogen levels. Many common migraine medications cannot be used in pregnancy due to toxicity to the fetus. Women who are considering pregnancy should speak with their doctors about migraine treatment options prior to conception. Nondrug therapies such as relaxation techniques, biofeedback, or ice packs may be helpful. Acetaminophen may be one option for the pregnant patient with migraines, but may not be effective in severe migraines. Available data on the safety of triptan use in pregnancy is too limited to make final conclusions.

A Word of Caution: Rebound Headaches

Overuse of antimigraine medications can lead to medication overuse headaches, or "rebound headaches" in about 2 out of every 100 people. Patients may have headaches almost every day. Rebound headaches can occur with most acute pain treatments used for migraines, including acetaminophen, NSAIDs, and triptans. Patients may find that they have to use increasingly larger doses of medication to treat the headache, which may in fact only worsen the rebound headache and lead to side effects. Speak with your doctor about treatment options if you find that your headaches are not relieved with prescribed doses of medications.

A Word of Caution: Butalbital Use in Migraine

Several prescription controlled drugs contain butalbital as a component of the medication, along with either acetaminophen, aspirin, caffeine and/or codeine. These drugs (Fiorinal, Fioricet, Phrenilin) have long been marketed and prescribed for tension-type or migraine headaches. While their short-term use might be useful for severe, acute migraine pain, butalbital and codeine are narcotic opioids with addictive potential. NSAIDs, acetaminophen, or triptans for more severe headaches, are preferable due to proven efficacy and lower risk for abuse. The efficacy of isometheptene-dichloralphenazone-acetaminophen (previously Midrin) is questionable for migraines.

Finished: Living with Your Migraines: Tips for Treatment and Prevention

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