Treatment and Prevention Tips for Living with Migraine Headaches
Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on Aug 24, 2020.
What is a Migraine Headache?
Do you have migraine headaches? If you do, you are not alone.
- In the U.S., roughly 40 million people suffer from migraines.
- Most people with migraine experience one to two migraine attacks per month. However, as many as 4 million people may have chronic migraine symptoms, with at least 15 migraine days per month.
- These attacks can be debilitating and prevent you from your normal daily activities, like work, school or recreation.
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, blurred vision, odd sensations (auras) and a greater sensitivity to light and sound.
Migraines tend to occur in those between 15 and 55 years of age, and are two times more common in women than men, possibly due to estrogen fluctuations. The frequency of migraine attacks can vary from a couple of times per year, to up to multiple times per month, to even daily.
Migraines Impact Your Quality of Life
Over 90% of people are not able to carry on their normal daily routine, whether it be work, school or parenting, when they experience a migraine.
And it can hit your wallet, too.
- Migraines tend to affect people in their working years. Nearly 160 million workdays are lost each year in the U.S. as a result of migraine.
- It is estimated that the cost of healthcare and the loss of productivity related to migraine is over $35 billion per year domestically.
- Employers who offer benefits may spend over $80,000 each year in migraine-related costs per 1000 employees.
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 may include:
- throbbing pain
- light and sound sensitivity
- nausea with or without 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. Often signals the onset of a migraine.
Does Everyone Have an Aura?
About 20% 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)
- ringing in the ears
- blurred vision
- seeing lines or bright lights
- vertigo (dizziness).
An aura may also occur during the headache or even without a headache. About 80% of migraine headaches are not preceded by an aura, but involve vague symptoms such as mental clouding, mood swings, and fatigue.
What Triggers a Migraine?
Many different items or events might trigger a migraine attack:
- certain foods, chemicals, or preservatives
- emotional stress
- hormone changes
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, artificial sweeteners, 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 or meals.
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 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.
What Are Your Migraine Options?
Migraine medications fall into several categories: Pain-relieving drugs can be taken early at the onset of the migraine to help stop a full-blown migraine and includes drug classes such as:
Alternatively, some medications can be taken every day to reduce migraine attacks (called preventive drugs) and may include drug classes like:
Newer, longer acting calcitonin gene-related peptide (CGRP) receptor antagonists are also now approved for migraine treatment or prevention.
- Aimovig (erenumab-aooe) from Amgen
- Ajovy (fremanezumab-vfrm) from Teva Pharmaceuticals
- Emgality (galcanezumab-gnlm) from Eli Lilly and Company
- Nurtec ODT (rimegepant sulfate) from Biohaven
- Ubrelvy (ubrogepant) from Allergan
- Vyepti (eptinezumab-jjmr) from Lundbeck Inc
In October 2019 Reyvow (lasmiditan) was approved for the acute treatment of migraine, with or without aura, in adults. Reyvow is an oral serotonin (5-HT) 1F receptor agonist, a new class of drugs for the acute treatment for migraine.
In May 2020, a new pain NSAID option was approved, Elyxyb (celecoxib oral solution) for treatment of acute migraines, from Dr. Reddy’s Laboratories.
Acute Migraine Treatments: OTCs and NSAIDs
Mild migraine headaches can be treated with over-the-counter (OTC) pain relievers such as:
- acetaminophen (Tylenol)
- nonsteroidal antiinflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin IB) or naproxen (Aleve).
If you have a history of stomach or intestinal ulcers or bleeding, NSAIDs or aspirin should typically not be used.
Caffeine may augment the effects of other pain relievers in products like:
OTCs are best used early at the onset of the migraine symptoms. Higher doses or prescription NSAIDs may be needed for moderately severe migraines -- ask your doctor.
A prescription NSAID, a celecoxib solution known as Elyxyb was approved for migraine treatment in May 2020. Elyxyb is from Dr. Reddy's Laboratories, Inc.
Is There a Cure for Migraines?
Not yet, but major leaps have been made in drug treatments and prevention 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) are a mainstay in the treatment of acute migraine headaches. Sumatriptan (Imitrex) was the first triptan, developed by Glaxo in 1992 and a major advance in the treatment of migraines.
- Sumatriptan is now available in a generic form for the oral tablets, nasal spray, prefilled syringes, and injection.
- The patch form of sumatriptan, called Zecuity, was has been discontinued and is no longer available. The manufacturer of Zecuity, Teva Pharmaceuticals, voluntarily withdrew Zecuity from the U.S. market because of the reports of serious burns or scars on the skin where the patch was worn.
Acute Migraine Treatments: Triptans
Serotonin 5-HT receptor agonists (triptans) are used early in the severe migraine to stop the migraine. Their use is preferred over habit-forming narcotics, such as aspirin, butalbital, and caffeine (Fiorinal) due to addiction concerns and other side effects.
Dosing options include oral tablets, orally-disintegrating tablets, subcutaneous (SQ) injections, prefilled pens for SQ injection, and nasal sprays and nasal powders.
Triptans are very effective, but should not be used in patients at risk for a heart attack or stroke. These agents act to constrict blood vessels and block pain messages in the brain.
Prescription medications in this class include:
Sumatriptan Approvals: Onzetra Xsail
Onzetra Xsail (sumatriptan nasal powder) is a unique breath-activated intranasal powder. It is a serotonin 5-HT1B/1D receptor agonist triptan used to treat acute migraine with or without aura in adults.
In approval 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.
- The maximum dose is two doses (44 mg/4 nosepieces) per 24 hours, OR one dose of Onzetra Xsail and one dose of another sumatriptan product, separated by at least 2 hours.
- The safety of treating an average of more than 4 headaches in a 30 day period has not been established.
Side effects include abnormal taste, nasal discomfort, and runny nose.
Latest Sumatriptan Approvals: Zembrace SymTouch
Zembrace SymTouch (sumatriptan), 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. Zembrace SymTouch may also be given at least 1 hour following a dose of another sumatriptan product.
Other injectable sumatriptan agents for migraine include:
Cost-saving generics are available, as well.
Acute Migraine Treatments: Ergots
Medications called ergotamines are also used to stop the development of a migraine and include treatments such as:
Ergot agents have activity at serotonin receptors involved in migraine attacks.
Most healthcare providers consider the triptan class 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.
Reyvow, Ubrelvy and Nurtec ODT OK'd for Acute Migraine Treatment
In October 2019 the FDA approved Eli Lilly’s Reyvow (lasmiditan) for the acute treatment of migraine, with or without aura, in adults. Reyvow is in a new class of medications for acute migraine treatment known as serotonin (5-HT) 1F receptor agonists. Doses are 50 mg, 100 mg, or 200 mg by mouth as needed but no more than once per 24 hours. The most common side effects (≥5% and > placebo) were dizziness, fatigue, paresthesia (skin tingling or numbness), and sedation. Patients should not drive or operate machinery until at least 8 hours after taking each dose of Reyvow.
In December 2019 Ubrelvy (ubrogepant) was also approved for acute migraine treatment in adults with or without aura. Ubrelvy is CGRP receptor antagonist from Allergan. In studies, both the 50 mg and 100 mg dose strengths demonstrated significantly greater rates of pain freedom and freedom from the most bothersome migraine-associated symptom at two hours, compared with placebo. The most common adverse reactions (at least 2% and greater than placebo) were nausea and somnolence. Ubrelvy will be commercially available in the first quarter of 2020.
In March 2020, Nurtec ODT (rimegepant) from Biohaven was given approval to treat acute migraine treatment in adults with or without aura. Like Ubrelvy, Nurtec ODT is a CGRP antagonist. The recommended dose is 75 mg taken orally, as needed, with a maximum dose of 75 mg in a 24-hour period. The safety of treating more than 15 migraines in a 30-day period has not been established. The most common adverse reaction was nausea (2%) in patients who received Nurtec ODT compared to 0.4% of patients who received placebo.
Preventive Migraine Treatments: Tricyclic Antidepressants
Oral 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.
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.
However, the anticholinergic effects of TCAs can be problematic in many patients. especially the elderly, and other options may be preferred.
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:
Side effects might include low blood pressure, dizziness, lack of energy, cold hands and feet, headache and reduced heart rate. Beta blockers may not always be suitable for people with certain heart or lung conditions, or people with diabetes or thyroid disease. Beta blockers can also cause low blood sugar (hypoglycemia).
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 like verapamil may include dizziness, drowsiness, constipation, low blood pressure or headache, but these can lessen over time.
Preventive Migraine Treatments: Anti-Seizure Medications
Certain anti-seizure medications (anticonvulsants), for example:
have been shown to be useful for migraine prevention. However, these drugs can be linked 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 your doctor stops treatment. Patients should discuss side effects with their doctors prior to treatment.
Preventive Migraine Treatments: Botox
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. Safety and effectiveness have not been established for the prevention of episodic migraine (14 headache days or fewer per month)
The generic name for Botox is onabotulinumtoxinA and it may be an option for those who have had limited success with more traditional treatments.
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.
A New Class: Aimovig is First CGRP
There have been limited new therapeutic options for patients with migraine over the last two decades. However, alternatives from a unique class of preventive migraine medications are now available. These new monoclonal antibodies are able to block either the calcitonin gene-related peptide (CGRP) receptor or the CGRP ligand to prevent receptor binding.
These agents are novel and long-acting. All three drugs have roughly the same price -- roughly $7,000 per year -- and manufacturers are working to make access easier for patients.
- Aimovig (erenumab-aooe), from Amgen, is the first FDA-approved CGRP receptor antagonist that works by blocking the activity of calcitonin gene-related peptide, a molecule that is released during migraine attacks.
- Aimovig is given once monthly as a subcutaneous (under the skin) injection. The suggested dose is 70 mg once monthly; however, some patients may benefit from a dosage of 140 mg once monthly
- In three studies of patients with episodic migraine, Aimovig-treated patients experienced 1 to 2.5 fewer monthly migraine days, on average, compared to placebo.
- Common side effects with Aimovig include injection site reactions and constipation.
Ajovy: The Latest CGRP Approvals
Ajovy (fremanezumab-vfrm), from Teva Pharmaceuticals, is a fully-humanized monoclonal antibody targeting the CGRP ligand for migraine prevention. It is the second approved CGRP migraine preventive; it binds to the CGRP ligand to block binding to the receptor.
- Ajovy is given as a subcutaneous injection once every month (225 mg) or once every three months (675 mg).
- In clinical studies, Ajovy was studied as both a stand-alone agent and combined with oral preventive medications. In these trials, patients experienced a reduction in monthly migraine days over a 12-week period.
- Common side effects were injection site reactions and infections.
Emgality and Vyepti: Binding to the Ligand
- Emgality is a calcitonin gene-related peptide (CGRP) monoclonal antibody that binds to the ligand and inhibits the activity of calcitonin gene-related peptide (CGRP). Dosing is 120 mg given once monthly by subcutaneous injection after an initial one-time loading dose (240 mg). Common side effects are injection site reactions; allergic reactions, such as rash, itching and shortness of breath were also reported.
- In June 2019, Emgality was also approved to treat episodic cluster headache in adults.
In Feb. 2020, Vyepti (eptinezumab-jjmr), from H. Lundbeck A/S, was approved by the FDA for the preventive treatment of migraine in adults. Vyepti is a humanized monoclonal antibody that binds to calcitonin gene-related peptide (CGRP) ligand and blocks its binding to the receptor.
- The recommended dose is 100 mg IV given every 3 months; some patients may benefit from a dose of 300 mg.
- The most common side effects (≥2%) were nasopharyngitis (common cold) and hypersensitivity (allergy).
Migraine Agents for Nausea and Vomiting
Nausea and vomiting are common with migraine headaches. In fact, nausea is reported by 73% of migraineurs and vomiting by 29%.
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:
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 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.
Hormones and 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 tend to respond well to NSAIDs and/or triptans.
One study found that women who suffer from migraines may be able to safely use hormone therapy to treat menopause symptoms. The study of 85,000 U.S. women found no evidence that hormone therapy carried a particular risk of heart attack or stroke among those with a history of migraine headaches.
Migraines in Pregnancy
Roughly 55% to 90% of women report an improvement in their migraines during pregnancy, probably due to stabilization of estrogen levels. However, many common migraine medications - like the ergots - 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 before pregnancy.
- 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.
- Other treatments may be possible when monitored by your doctor.
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 (2%).
Patients may have headaches almost every day. Rebound headaches can occur with most acute pain treatments used for migraines, including:
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
Several prescription controlled drugs contain butalbital or narcotics (such as codeine) as a component of the medication, along with either acetaminophen, aspirin, or caffeine. These drugs (Fiorinal, Fioricet) have long been marketed and prescribed for tension-type or migraine headaches.
- Butalbital and codeine are narcotic opioids with addictive potential.
- In one study, researchers found that injectable prochlorperazine given in the emergency room was far superior to use of hydromorphone Dilaudid, another injectable opioid, for migraine.
- Doctors and patients should consider available alternatives before using opioids for quick relief of migraine pain.
Finished: Treatment and Prevention Tips for Living with Migraine Headaches
Trouble falling or staying asleep is one of the most common medical complaints. Sometimes, just a few simple changes in lifestyle can make a big impact so you can get the shut-eye you need.
Society tends to treat menopause as a disease; something to be avoided at all costs. But menopause can be positive. No more monthly mood swings, period accidents, or pregnancy worries. Self-confidence and self-knowledge...
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