Living with Your Migraines: Tips for Treatment & Prevention
What is a Migraine Headache?
What happens during a migraine? Not everyone has the same symptoms, but 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 in those 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?
And it can hit your wallet, too; 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. Migraine sufferers use double the amount of prescription drugs, emergency visits, and doctor appointments as those who are migraine-free.
How Can I Tell if I Have a Migraine?
Common symptoms that occur during a migraine typically 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 - Not present in all migraines; may have vision or hearing changes, or sense an unusual smell or taste
Does Everyone Have an Aura?
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 Can Trigger My Migraines?
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?
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 to 2 day phase after the attack defined by tiredness 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?
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 could 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, generic availability, and costs should also be considered.
Acute Migraine Treatments: OTCs
OTCs are best used early when the symptoms just start. Higher doses or prescription NSAIDs may be needed for moderately severe migraines - ask your doctor. If you have a history of stomach or intestinal ulcers or bleeding, NSAIDs or aspirin should typically not be used.
Is There a Cure for Migraines?
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, a major advance.
Sumatriptan is now available in a generic form for the oral tablets, nasal spray, prefilled syringes, and injection. The patch form, called Zecuity, was approved by the FDA in January 2013 and is not yet generic. In adults, one Zecuity patch is applied to the skin and left in place for 4 hours. No more than 2 patches should be used in a 24-hour period.
Acute Migraine Treatments: Triptans
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).
Latest Sumatriptan Approvals: Onzetra Xsail
Onzetra Xsail (sumatriptan nasal powder) is a unique breath-activated intranasal powder approved in February of 2016. From Avanir Pharmaceuticals, it is a serotonin 5-HT1B/1D receptor agonist triptan used to treat acute migraine (with or without) aura in adults. In studies, migraine relief was significantly greater with Onzetra Xsail patients (41.7%) compared to placebo (26.9%) at 30 minutes and for up to two hours after the dose.
The recommended dose of Onzetra Xsail is 22 mg (2 nosepieces), administered using the Xsail breath-powered delivery device. This dose may be repeated in 2 hours if needed (max dose 4 nosepieces per 24 hours). Side effects included abnormal taste, nasal discomfort, and runny nose.
Latest Sumatriptan Approvals: Zembrace SymTouch
Zembrace SymTouch Injection
Zembrace SymTouch (sumatriptan), also approved in February 2016, is another 5-HT1B/1D receptor agonist for the treatment of acute migraine episodes with or without aura in adults. Zembrace SymTouch comes as a prefilled, single-dose subcutaneous (under the skin) autoinjector.
Developed by Dr. Reddy’s Laboratories, the dose of Zembrace SymTouch is 3 mg injected subcutaneously with a max dose of 12 mg in 24 hours (4 injections). Each injection should be given at least 1 hour apart, if needed. Other injectable sumatriptan agents for migraine include Imitrex, Sumavel DosePro, and Alsuma. Cost-saving generics are available, as well.
Acute Migraine Treatments: Ergots
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
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
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, 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
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). Plus, valproic acid should not be used in pregnancy. Topiramate may cause a sensation of tingling, burning (paresthesias), 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
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
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
Triptans or anti-inflammatory 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.
Hormones and Menstrual Migraines
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.
Migraines in Pregnancy
Women who are considering pregnancy should speak with their doctors about migraine treatment options prior to conception. Non-drug 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.
For women with severe symptoms who do not respond to other options, triptans can be considered. Most data exists on sumatriptan. A registry (Headache, 2014) in which over 600 pregnant women reported use of sumatriptan during pregnancy did not find an increased risk of birth defects in infants exposed to sumatriptan.
A Word of Caution: Rebound Headaches
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.
Another Word of Caution: Butalbital or Opioid Use in Migraine
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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