The Basics of Migraine Treatment
Most people are familiar with the more common ways to stop a migraine attack in progress. Many have even heard of various treatments used to prevent or reduce the frequency of migraine attacks. Yet few people understand the basics of how migraine is treated and why. Most people I encounter who live with migraine have no idea that treating migraine involves a multi-pronged approach. When I do explain it, people are often shocked to discover that the basics were not offered by their own doctor.
Ask anyone with migraine and they will tell you. When a migraine attack strikes, the top priority is to get it stopped quickly and with as little interference to life as possible. The simplest, safest, and cheapest abortive is sleep. The trick is actually being able to fall asleep and stay asleep long enough. Because it isn’t always practical to take a nap (and like everything else, doesn’t always work), these other options are essential to any migraine treatment plan.
In the case of mild episodic migraine, over-the-counter NSAIDs are sometimes sufficient to abort an attack. These include medicines containing aspirin or naproxen, and occasionally caffeine. Simple analgesics like acetaminophen are ineffective to abort a migraine attack.
The first-line treatment for an acute migraine attack is a class of drugs known as triptans. These medicines have a long track record of safe and effective use for most patients. However, there are exceptions. Some patients have comorbid health problems for which triptans are contraindicated. Some cannot tolerate the side effects while others receive no benefit from their use at all. That’s when other options are considered. In addition to triptans, NSAIDs are also used as migraine abortives. Less frequently, DHE may also be used.
Historically, barbiturates and opioids were used to treat the pain of a migraine attack. However, these medicines are rarely used anymore because of a high risk of dependency and medication overuse headache. Neither of these medication classes actually aborts a migraine attack in progress. They merely reduce the sensation of pain until the attack subsides on its own.
For patients who experience infrequent attacks that are quickly aborted, preventives are probably not warranted. However, most people can benefit from preventive therapy. When attacks occur 2-4 times per month and disrupt work, family, and social life, it’s time to talk to your doctor about a preventive. Early intervention is the key to preventing migraine from becoming chronic and disabling. Unfortunately, few people realize how important it is to start preventives so early. Most wait until migraine threatens employment and relationships before ever talking to a doctor. Even when a patient does ask about migraine treatment, less than half actually receive the medically-appropriate preventive treatment.
There has never been a treatment developed specifically for migraine prevention. The drugs and treatments available have been borrowed from other disciplines based on decades of clinical evidence that they help some patients. None are without side effects and do not help more than half of those who try them. To be considered successful, these treatments must reduce the frequency and/or severity of attacks by 50%. It is rare to find a treatment that completely suppresses all attacks.
Finding the right preventive (or combination of preventives) can take many years. Each treatment must be given a full 90-day trial to determine its effectiveness. If a change in dose is needed, then 90 days at each new dose is necessary. Patients need to be prepared for this long period of trial-and-error. Understanding the process can increase compliance and commitment to the process. Doctors have a lot of options to choose from when recommending a preventive therapy. With dozens of drugs and treatments in each class, it would take a lifetime to try them all. It’s simply impossible to have tried everything. If you’ve been told that there are no more options, then it’s time to find a new doctor.
There are hundreds of options in many different treatment classes!
- tricyclic antidepressants
- anti-seizure medicines
- beta blockers
- calcium channel blockers
- NMDA receptor antagonists
- botulinum toxin
- vitamins & minerals
- transcutaneous electrical nerve stimulation
- vagus nerve stimulation
- transcranial magnetic stimulation
**For a complete list of possible preventives, take a look at this list compiled by my good friend, Teri Robert.**
Plus, there’s good news on the horizon. Three pharmaceutical companies are in a race to be the first-to-market with a new class of drugs designed specifically to prevent migraine attacks. They’re called calcitonin gene-related peptide antagonists (CGRP) and have shown amazing promise in early trials. If you have migraine and haven’t found a good preventive yet, keep watching for news about these drugs. Their debut will change the face of migraine medicine and bring hope to millions.
Even the best treatments don’t always work as planned. When an attack rages uncontrolled and none of your abortive options are helping, it’s time for rescue treatments. Visiting an emergency room for treatment of an unresponsive migraine isn’t the best solution. ERs are for emergencies and, thus, are poorly equipped to address the rescue treatment need of most migraine patients. The wait times, high costs, and excessive testing are inappropriate for a migraine attack that does not respond to abortive treatment.
NOTE: There are rare times when seeking ER treatment for migraine is appropriate. Read What is a Migraine Emergency? for more details.
This is the most neglected aspect of migraine treatment. A medically-appropriate response to abortive failure is home use of rescue treatments. However, few doctors (even headache specialists!) discuss this issue with patients or help them to plan for this inevitable occurrence. In most cases, it is the patient who starts this conversation. If you ask about rescue treatments and your doctor recommends the ER, do not accept that answer. There are safe, effective rescue treatments that are available by prescription. Insist on appropriate treatment.
- anti-emetics to control nausea and vomiting
- muscle relaxers to promote sleep and relaxation
- prescription-strength NSAIDs to reduce pain
- anxiolytics to promote relaxation
- short-lasting opioids for stronger pain control