The Many Ways to Manage Migraine Treatment

migraine treatment

Those who have experienced migraines know that they are very different from tension headaches. 

A migraine “affects not just the head, but so many other body systems,” says Jill Dehlin, an RN and patient advocate who works with migraine patients and struggles with migraines herself. “Somebody with a headache will maybe have a throbbing on both sides of their temples. But with the migraine, they might have nausea and vomiting. They might have diarrhea or constipation. They might have dizziness or blurred vision, double vision, cognitive problems.” She added that her own migraines can cause her to jumble words, for example, referring to “bagels” as “muffins.” When migraines are  severe, she adds, “it feels like somebody drilled a hole into my head and poured hot acid in it.”

Migraines are a complex type of pain and many patients experience various combinations of symptoms and triggers. Midori Matsuo, bachelor of medicine bachelor of surgery (MBBS) and a pain management doctor, notes that it’s usually neurologists and pain specialists who end up treating patients with migraines.

“Primary care doctors, by and large, don’t get a lot of training in headaches,” adds Dehlin. 

Over the past few years, there has been a small number of migraine drugs approved. For the most part, preventive migraine treatments have been drugs like beta blockers, anti-seizure medicines or Botox, used off-label. 

Migraine pain, even pain localized in the head, is unique for each person. Our brains have several different pathways that both trigger and block pain, explains Matsuo, and different treatments like anticonvulsants, antidepressants, opioids and nonsteroidal anti-inflammatories (NSAIDS) each block separate pathways. Different migraine drugs or combinations of drugs may work, or not, for each patient. Dehlin warns that it can take time to test a drug, and then more time to wean off of it if the treatment is ineffective or causes unmanageable side effects.

“I personally have tried over 60, six-zero, different kinds of preventive and acute treatments,” Dehlin adds, “The main reason I quit taking them was because of the side effects.” Today she uses a combination of beta blockers, biofeedback and diet and exercise to minimize migraines.

Drugs That Stop a Migraine in Its Tracks (Acute Treatment)

If you have migraines only a few times a month, you’ll probably start with what’s called “abortive drugs.” Your doctor will instruct you to take these migraine drugs as needed at the first sign of a migraine. The sooner you take them, the more effective they’re likely to be. They may decrease the severity of your migraine as well as its length from three days down to three hours, for example. “Usually, we start with nonsteroidal anti-inflammatory drugs,” says Matsuo.

Nonsteroidal Anti-inflammatory Drugs (NSAIDS)

NSAIDs like Advil and ibuprofen are commonly used over-the-counter drugs that can treat pain and fever throughout the body. There are stronger NSAIDS you can only get with a prescription from your healthcare provider. The drugs work by blocking the effects of prostaglandins — compounds that promote inflammation when you have an injury that needs to be healed. But prostaglandins also have other functions like protecting your stomach lining from acid. Using NSAIDs, especially at higher doses or for longer periods of time, can yield side effects, including:

Vomiting

Diarrhea

Constipation

Heartburn

Rashes

Dizziness

Liver failure, kidney failure, heart attack and ulcers (in some cases, particularly when the drugs are needed frequently or in large doses) 

Triptans

Triptans mimic serotonin, a chemical in your brain that can help calm pain and restrict blood vessels. The drugs can also reduce nausea and sensitivity to light and sound. While most triptans are manufactured as pills, if you struggle with nausea and vomiting, your doctor may suggest a nasal spray instead. Triptans are more effective the earlier they are used. Dehlin suggests taking them at the very first hint of a migraine. “If you wait until you’re really in the severe pain phase of a migraine, the triptan becomes less effective,” she adds.

Side effects include:

Dizziness

Dry mouth

Fatigue

Tingling sensation

Gastrointestinal (GI) effects

Feeling hot or cold

Heart attack and stroke

Opioids

Opioids are often the last choice prescribed to control acute pain during a migraine, due to their highly addictive nature. They stimulate receptors in your brain that regulate pain and pleasure. Though effective for some types of pain, opioids come with the significant risk of developing a substance-use disorder when taken for multiple days. Be sure to discuss this possible outcome with your doctor. Taking too high a dose of opioids can also lead to a fatal overdose.

Taking them can also result in other side effects, including:

Drowsiness

Euphoria

Constipation

Vomiting

Urine retention

Lowered blood pressure (which can be dangerous)

Insomnia

Matsuo says that insomnia can be one of the most debilitating side effects. If her patients need opioids, but also can’t sleep while using them, she may recommend melatonin, a supplement that aids in sleep, or insomnia treatments like zolpidem, (Ambien, Ambien CR, Edluar, Zolpimist, Intermezzo)

Preventive Drugs

Most of the drugs used to avert migraines are taken chronically to manage other conditions like high blood pressure or epilepsy. Over time, patients and researchers have noted that patients who used these medications reported fewer migraines. But in recent years, several drugs in a new class, called calcitonin gene-related peptide (CGRP) antagonists, have been approved  to prevent migraines.

Calcitonin Gene-Related Peptide (CGRP) Antagonists

CGRP is a protein that dilates blood vessels, particularly in the brain, allowing for an increase in blood flow. In the early 1990s, researchers discovered that CGRP was involved in migraine headaches. CGRP antagonist injections, including fremanezumab (Ajovy), galcanezumab (Emgality) and eptinezumab (Vyepti), work by blocking its action. Despite the fact that these drugs are designed to treat migraines, Dehlin says the insurance companies have made them difficult to access. The reason is, they’re more expensive than other treatments like beta blockers and anti-seizure drugs that have been on the market much longer. 

Still, even drugs developed to treat migraines come with side effects. The Food and Drug Administration (FDA) recently reported that one CGRP antagonist, erenumab (Aimovig), was associated with an increase in blood pressure. Seven of the high blood pressure cases in this study were so severe they led to the patients’ hospitalizations.

Other adverse effects include:

Constipation

Gastrointestinal (GI) disorders

Muscle cramps and spasms

Injection-site reactions

Hormonal Birth Control

Migraines are more common in women than in men, and many women find that they can be triggered during certain points in their menstrual cycles. For some women, this minimizes migraines, but for others, it can make them more frequent. Cat Ekkelboom-White, a migraine patient whose mother and grandmother also suffer from migraines, noticed early on that hers were triggered by menstruation. So, she says, “the first port of call was to put me on the contraceptive pill to help, which it did, but it didn’t stop [the migraines.]” Because she still needed more relief, she was prescribed triptans. Unfortunately, both triptans and contraceptives can increase your risk for blood clots and stroke. Eventually, she stopped taking them.

Other side effects are:

Breast tenderness

Period changes (lighter bleeding or spotting between periods)

Nausea

Mood swings

Fluid retention

Weight gain

Anticonvulsants

Seizures are a result of excess neuronal activity. Anticonvulsants decrease this activity and it’s thought that this same mechanism helps prevent migraines as well.

Ekkelboom-White believes pandemic stress worsened her migraines this year and that triptans weren’t enough to control them. As a result, her physician suggested topiramate, the anticonvulsant most commonly used to treat migraines. “I had a super-good reaction to it,” she says. “They did warn me that [the drug] could come with depression, but I think generally I’m fine.”

Matsuo warns that there is an adjustment period with these drugs. “When we use anticonvulsants, we have to tell the patients that at first, they will feel dizzy. They will be sleepy. Sometimes, they have distal tremor in their hands. But also, this will be only for a couple of weeks. After three weeks, your brain is completely adapted to the medication,” she says.

Other side effects of topiramate include:

Nausea

Cognitive changes

Fatigue

Beta Blockers

Beta blockers lower your blood pressure. Since migraines cause dilated blood vessels and a rush of blood to the brain, beta blockers can help prevent them. Dehlin takes them now to block her migraines, but emphasizes she does notice side effects. “When I exercise at a peak performance, my maximum heart rate is around 83. That’s not enough to keep my muscles going,” she says. Additionally, since the drugs slow your heart rate, they can cause problems like renal disease or reduce circulation to your extremities. You may also tire more easily. 

Other side effects include:

Dizziness

Weight gain

Constipation

Nausea

Muscle and joint pain

Shortness of breath

Insomnia

Depression

Botox

Botox injections reduce wrinkles by preventing your muscles from contracting. The same action, if directed to the appropriate spot, can also help reduce migraines in some patients.

Side effects include:

Bruising at the injection site

Flulike symptoms

Drooling

Although rare, difficulty swallowing

Antidepressants

Antidepressants can help limit migraines by increasing serotonin – the same molecule that triptans mimic — in your brain. While several types of antidepressants may alleviate the symptoms of migraines, those typically used for migraine treatment are tricyclic  antidepressants, including amitriptyline (Elavil), imipramine (Tofranil) and nortriptyline (Pamelor). These drugs should not be taken with triptans, because it can cause a dangerous buildup of serotonin that can raise your blood pressure and lead to hallucinations.

Side effects of antidepressants include:

Nausea

Vomiting

Diarrhea

Constipation

Insomnia

Mood swings

Fatigue

Reduced sex drive

Weight gain

Suicidal ideation

Birth defects

High blood pressure 

 

Non-Pharmaceutical Strategies

Journal and Triggers

In addition to pharmaceutical migraine treatment, “I recommend to everyone that I speak with to keep a journal or diary and keep track of how many days a week, how many times a day you are having head pain and the nature of the head pain,” says Dehlin. “The nature of the head pain is really important because [a] migraine has specific symptoms: one-sided throbbing, light sensitivity, sound sensitivity, sensitivity to fragrances, nausea, vomiting, GI problems, dizziness [and] visual problems. A person should be documenting these kinds of symptoms [regularly].” 

That can help tell patients how well a certain treatment regimen is working and lead them to identifying foods or other triggers they can then avoid.

By keeping track of your headaches and moods and foods in a journal, you may discover patterns to help lessen migraines. For example, if you drink red wine one night and you find you’re likely to have a migraine the next day, then you can avoid red wine. You may find that stress is a trigger. While you can’t avoid stress entirely, you can consider incorporating techniques to minimize it, like practicing mindfulness meditations or reducing your workload when possible. “I do some stress-reduction techniques that, when I’m in a severe attack, really helps me to be able to breathe and focus on my breath,” says Dehlin. “Many people will do a meditation every day, just to center themselves.”

Barometric Pressure

Some people find that shifts in barometric pressure is a trigger. Unfortunately, says Dehlin, “you can’t really control the weather.” However, if you keep an eye on the forecast, you may be able to prepare for the possibility of a migraine. If the pressure is about to drop, have your abortive drugs handy, so that you can take them at the first sign of a migraine. 

WeatherX is a cell phone app that tracks barometric pressure and can alert you to changes in your area. The company behind the app also sells special earplugs that may help prevent migraines by limiting pressure changes in your ear canals when the barometric pressure drops. Note, though, that this device has not been evaluated by the FDA. 

Acupuncture

Some research has suggested that acupuncture can help relieve headaches and migraines. Two studies, one in JAMA and another in  the BMJ suggest that true acupuncture is more effective than sham acupuncture (a process in which a professional pretends to give acupuncture treatments to patients in hopes of teasing out the difference between a placebo effect and true efficacy of acupuncture treatments).

Biofeedback

Biofeedback is a technique that allows you to visualize – and learn to control – physiological processes in your brain as well as in the head, neck and shoulder muscles. The technician will attach sensors to you that transmit signals to a computer. You face the computer screen and see how tensing and relaxing different muscles impacts your blood flow to different areas and affects your heart rate and body temperature. It allows patients to practice techniques to prevent migraines from happening when they feel them coming on. The research on biofeedback’s efficacy is mixed, but its side effects are limited to an investment in time and money.

“Another thing that we did, which is quite mind-blowing, was to put the sensor on the side of my head to check the blood flow to my brain,” says Ekkelboom-White. “Often when you feel a migraine coming on, you can feel the tingling in the side of your head. And that’s because you’ve got this rush of blood going into the brain. If you start to feel that tingling, you can actually use your thoughts to restrict the blood vessels, to narrow them so that you’re restricting how much blood is flowing through. And you can actually see that on the screen. When you can sit and focus on these thoughts, it actually has that effect.”


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