Living with Migraine Headaches: Treatment & Prevention Tips
Medically reviewed on Jul 15, 2018 by L. Anderson, PharmD.
What is a Migraine Headache?
Do you have migraine headaches? If you do, you are not alone. In the U.S., roughly 39 million people suffer from migraines, and more than 4 million people have daily migraine symptoms, with at least 15 migraine days per month.
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 can vary from a couple of times per year, to up to multiple times per month, to even daily.
How Do Migraines Impact Your Quality of Life and Wallet?
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. It is estimated that roughly $5.6 billion to $17.2 billion is lost in work productivity each year due to the impact of migraines. The World Health Organization (WHO) ranks migraine as the 19th most common reason for disability.
Medical costs due to the diagnosis and treatment of migraines surpasses $2 billion annually. Migraine sufferers use double the amount of prescription drugs, emergency visits, and doctor appointments as those who are migraine-free. The average monthly healthcare costs for migraine sufferers is roughly $145 compared to about $89 per month for those without migraines.
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 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 Can Trigger My Migraines?
Many different items or events might trigger a migraine attack:
- certain foods
- 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.
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.
Migraine Treatments: What Are the 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, medications can be taken every day to reduce migraine attacks (called preventive drugs) and includes drug classes like:
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.
Longer-acting, once-monthly monoclonal antibodies are now approved or under research for migraine prevention. A calcitonin gene-related peptide (CGRP) receptor antagonist Aimovig (erenumab-aooe), from Amgen, was FDA-approved in May 2018.
Acute Migraine Treatments: OTCs
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 when the migraine symptoms just start. Higher doses or prescription NSAIDs may be needed for moderately severe migraines - ask your doctor.
Is There a Cure for Migraines?
Not yet, but major leaps 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, 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 (upper arm or thigh only) and left in place for 4 hours. No more than 2 patches should be used in a 24-hour period.
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 butalbital due to addiction concerns.
Dosing options include tablets, injections, patches 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:
Latest Sumatriptan Approvals: Onzetra Xsail
Onzetra Xsail (sumatriptan nasal powder) is a unique breath-activated intranasal powder approved in February 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 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.
Other injectable sumatriptan agents for migraine include Imitrex, Sumavel DosePro, and Alsuma. 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.
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.
The anticholinergic effects of TCAs can be problematic in 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:
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, may occur, 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
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.
A New Class: Calcitonin Gene-Related Peptide (CGRP) Agents
There have been limited new therapeutic options for patients with migraine over the last two decades. The first agent in a new class of preventive migraine agents was approved in May 2018. These new monoclonal antibodies are able to block either the calcitonin gene-related peptide (CGRP) receptor or the CGRP ligand. These agents are novel and long-acting.
- 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 injection.
- 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.
Other CRGP agents in the research pipeline for migraine prevention include:
- Fremanezumab, from Teva Pharmaceuticals, is a fully-humanized monoclonal antibody targeting the CGRP ligand (not the receptor) and is in development for migraine prevention. Fremanezumab is being studied as a quarterly or monthly subcutaneous injection. The final FDA action date for approval of fremanezumab is September 16, 2018 (PDUFA date). Studies for chronic cluster headache were discontinued in June 2018 as primary endpoints were not met.
- Emgality (galcanezumab), from Eli Lilly, is also under research for prevention of migraine and cluster headaches. Emgality is a once-monthly, self-administered CGRP antibody. It works as a monoclonal antibody specifically designed to bind to and inhibit the activity of calcitonin gene-related peptide (CGRP). The FDA is expected to make a final decision on approval for Emgality by the end of September 2018.
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:
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 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 respond well to NSAIDs and/or triptans.
A 2017 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 percent 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 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 in conjunction with your healthcare provider. Most data exists on sumatriptan. As reported in Headache, in a registry in which over 600 pregnant women reported use of sumatriptan during pregnancy, an increased risk of birth defects in infants was not documented.
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.
Another Word of Caution: Butalbital or Opioid Use in Migraine
Several prescription controlled drugs contain butalbital or narcotics as a component of the medication, along with either acetaminophen, aspirin, or caffeine. These drugs (Fiorinal, Fioricet, Phrenilin) have long been marketed and prescribed for tension-type or migraine headaches.
While their short-term use might seem reasonable for severe, acute migraine pain, butalbital and codeine are narcotic opioids with addictive potential. In a 2017 study, researchers found that IV prochlorperazine given in the emergency room was far superior to use of hydromorphone, another opioid, for migraine. Doctors and patients should consider available alternatives before using opioids for quick relief of migraine pain.
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 Migraine Headaches: Treatment & Prevention Tips
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