Treatment of migraines

Why is treatment of migraines so important?

Migraines are a common headache disorder. More than 37 million people in the United States suffer from migraines. Two to three million migraine sufferers are chronic. More than 11 million people blame migraines for causing moderate to severe disability. More than 90% of people who suffer migraines miss work or cannot function normally during a migraine attack.

Ways to treat an acute migraine attack

For patients with milder and infrequent migraines, sometimes an over the counter NSAID, such as naproxen, is sufficient to treat the migraine. NSAIDs can increase the risk of gastrointestinal hemorrhage, so they must be used as infrequently as possible. Naproxen is a better option than Ibuprofen, because naproxen is effective for a longer time compared to ibuprofen.

For patients with more severe and infrequent migraines, triptans, such as sumatriptan, naratriptan, eletriptan, frovatriptan, can be taken at the onset of the migraine, alone or with an NSAID, such as naproxen. The triptans can be taken orally, intranasally (in the nose), or by injection under the skin. The intranasal and injection use can be beneficial particularly with those patients who have nausea and vomiting associated with their migraines. Triptans cannot be used in all patients with migraines, for example, in patients who are pregnant, in patients with a history of prior stroke or who have migraines associated with neurologic symptoms including loss of speech, weakness of a limb or limbs, or focal numbness (complicated migraines).

Medications to manage the nausea are also helpful in managing migraine. Prochlorperazine has been shown to decrease both nausea and headache severity, while other antinausea medications are helpful for nausea but not necessarily with the headache.

What if the headaches are frequent or chronic?

The goal of migraine management is to use as few doses of the acute migraine medications as possible. When patients use acute headache medications more than approximately twice a week, they run the risk of medication overuse headache, in which the frequent use of pain medications can lead to an increase in the frequency and severity of migraines.
For patients who have more frequent headaches (more than 1-2 headaches a week), then they would benefit from a prophylactic medication.

A migraine prophylactic agent is a medication that needs to be taken every day to prevent migraines from occurring. They decrease the number of migraines that a person has, and also decrease the severity of migraine symptoms, such as pain. The drug is considered successful if the frequency is decreased by 50%.

There are various medications in this category which fit multiple classes:
Blood pressure medications (Antihypertensives)
Seizure medications (Antiepileptics)
Antidepressants
Alternative therapies

Antihypertensives include beta blockers, calcium channel blockers. There is significant evidence that beta blockers are effective in migraine reduction. These include Propranolol and Nadolol. There is less evidence for the use of calcium channel blockers, but they can be effective in patients with complicated migraines (migraines associated with neurologic symptoms). These include Verapamil and Nifedipine.

Antiepileptics include Valproic acid and Topiramate. Both of these drugs have significant evidence that they are effective in migraine reduction. Other antiepileptic agents such as Gabapentin and Lamotrigine have been used in migraine prevention, but there is less evidence available proving that they are effective in migraine reduction. Lamotrigine has been shown to be ineffective in migraine prevention.

Antidepressants include tricyclic antidepressants and selective serotonin norepinephrine reuptake inhibitors. There is significant evidence that tricyclic antidepressants are effective in migraine reduction. The only selective serotonin norepinephrine reuptake inhibitor with significant evidence for migraine reduction is venlafaxine. Selective serotonin reuptake inhibitors have been used for migraine prevention but there is not a lot of evidence which provide that they are effective in migraine reduction.

The limiting factor with the use of the medications listed above is side effects. Each medication listed above has a list of side effects associated with them, which can make it difficult to use in certain patients. Also pregnancy prevents the use of the above medications.

Because of that, alternative therapies are also considered.
The alternative therapy with the best evidence for migraine prevention is Butterbur, which is used primarily in Europe. The dose is not standardized, and it is difficult to obtain a reliable source of Butterbur since it is not regulated as are pharmaceuticals. It cannot be used in pregnancy either.

Other alternative therapies include magnesium, vitamin B2, Coenzyme Q10, and feverfew.
What about women who have migraines associated with their menses (and not at other times)?
The medications used in these patients include triptans, such as frovatriptan, naratriptan, and zolmitriptan.

What about patients whose migraines do not improve on the migraine prophylactic agents?

Botox is shown to be effective in 80% of patients with chronic migraines. It is generally well tolerated with few side effects.

Nonmedication approaches for migraine prevention

The first option which is FDA approved, is the Cefaly headband. It emits microimpulses, stimulating the trigeminal nerve, and has been shown to decrease migraine severity and frequency. It is used for twenty minutes a day. It can be obtained by prescription.
People with migraines can also help decrease the frequency and severity of their migraines by making certain lifestyle changes. They include diet, exercise, sleep habits, hydration, biofeedback, relaxation training.

Diet

People with migraines can have certain triggers which include Monosodium glutamate and aspartame. A diet high in simple sugars can also increase migraine frequency. People with migraines tend to do better with a diet high in fiber, vegetables, and protein. Smaller, more frequent meals seem to be beneficial, by keeping blood sugar steady.

High amounts of Caffeine can lead to an increase in migraine frequency. However, moderate use of caffeine can be beneficial for migraine management.

Exercise

Aerobic exercise, at least 30 minutes a day, three times a week, has been shown to decrease migraine frequency as much as the preventative agents.

Sleep habits

Oversleeping by more 30 minutes increases the likelihood of awakening with a migraine. Keeping a strict wakeup time helps to decrease headache frequency. If still tired, one can take a nap later on in the day.

Hydration

Dehydration can cause and worsen headaches. I recommend drinking at least half of your body weight (in pounds) of water, throughout the day. If you are active, or work in a physical job, then you would need to increase your fluid intake. If you are feeling thirst, than you are already dehydrated, and need to fix that.

Relaxation techniques and Biofeedback

Some people have found benefits from relaxation techniques, biofeedback and cognitive behavioral therapy. Massage is also beneficial, but is usually effective for a brief period of time.