Diagnosis and Treatment of Migraine

Your treatment strategy depends on the frequency and severity of your headaches, the degree of disability your headaches cause, and your other medical conditions.

Some medications aren’t recommended if you’re pregnant or breast-feeding. Some medications aren’t given to children. Your doctor can help find the right medication for you.

Pain-relieving medications

Take pain-relieving drugs as soon as you experience signs or symptoms of a migraine for the best results. It may help if you rest or sleep in a dark room after taking them. Medications include:

• Pain relievers. Aspirin or ibuprofen (Advil, Motrin IB, others) may help relieve mild migraines.

  Acetaminophen (Tylenol, others), also may help relieve mild migraines in some people.

  Drugs marketed specifically for migraines, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraine pain. They aren’t effective alone for severe migraines.

  If taken too often or for long periods of time, these medications can lead to ulcers, gastrointestinal bleeding and medication-overuse headaches.

  The prescription pain reliever indomethacin may help thwart a migraine and is available in suppository form, which may be helpful if you’re nauseated.

• Triptans. These medications are often used in treating migraines. Triptans make blood vessels constrict and block pain pathways in the brain.

  Triptans effectively relieve the pain and other symptoms that are associated with migraines. They are available in pill, nasal spray and injection form.

  Triptan medications include sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), naratriptan (Amerge), zolmitriptan (Zomig), frovatriptan (Frova) and eletriptan (Relpax).

  Side effects of triptans include reactions at the injection site, nausea, dizziness, drowsiness and muscle weakness. They aren’t recommended for people at risk of strokes and heart attacks.

  A single-tablet combination of sumatriptan and naproxen sodium (Treximet) has proved to be more effective in relieving migraine symptoms than either medication on its own.

• Ergots. Ergotamine and caffeine combination drugs (Migergot, Cafergot) are less effective than triptans. Ergots seem most effective in those whose pain lasts for more than 48 hours. Ergots are most effective when taken soon after migraine symptoms start.

  Ergotamine may worsen nausea and vomiting related to your migraines, and it may also lead to medication-overuse headaches.

  Dihydroergotamine (D.H.E. 45, Migranal) is an ergot derivative that is more effective and has fewer side effects than ergotamine. It’s also less likely to lead to medication-overuse headaches. It’s available as a nasal spray and in injection form.

• Anti-nausea medications. Medication for nausea is usually combined with other medications. Frequently prescribed medications are chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro).
• Opioid medications. Opioid medications containing narcotics, particularly codeine, are sometimes used to treat migraine pain for people who can’t take triptans or ergots. Narcotics are habit-forming and are usually used only if no other treatments provide relief.
• Glucocorticoids (prednisone, dexamethasone). A glucocorticoid may be used with other medications to improve pain relief. Glucocorticoids shouldn’t be used frequently to avoid side effects.

Preventive medications

You may be a candidate for preventive therapy if:

• You have four or more debilitating attacks a month
• If attacks last more than 12 hours
• If pain-relieving medications aren’t helping
• If your migraine signs and symptoms include a prolonged aura or numbness and weakness

Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks. It may take several weeks to see improvements in your symptoms.

Your doctor may recommend daily preventive medications, or only when a predictable trigger, such as menstruation, is approaching.

Preventive medications don’t always stop headaches completely, and some drugs cause serious side effects. If you have had good results from preventive medicine and your migraines are well-controlled, your doctor may recommend tapering off the medication to see if your migraines return without it.

The most common medications for migraine prevention include:

• Cardiovascular drugs. Beta blockers, which are commonly used to treat high blood pressure and coronary artery disease, may reduce the frequency and severity of migraines.

  The beta blockers propranolol (Inderal LA, Innopran XL, others), metoprolol tartrate (Lopressor) and timolol (Betimol) have proved effective for preventing migraines. Other beta blockers are also sometimes used for treatment of migraine. You may not notice improvement in symptoms for several weeks after taking these medications.

  If you’re older than age 60, use tobacco, or have certain heart or blood vessel conditions, doctors may recommend you take a different medication.

  Another class of cardiovascular medications (calcium channel blockers) used to treat high blood pressure also may be helpful in preventing migraines and relieving symptoms. Verapamil (Calan, Verelan, others) is a calcium channel blocker that may help prevent migraines with aura.

  In addition, the angiotensin-converting enzyme inhibitor lisinopril (Zestril) may be useful in reducing the length and severity of migraines.

• Antidepressants. Tricyclic antidepressants may be effective in preventing migraines, even in people without depression.

  Tricyclic antidepressants may reduce the frequency of migraines by affecting the level of serotonin and other brain chemicals. Amitriptyline is the only tricyclic antidepressant proved to effectively prevent migraines. Other tricyclic antidepressants are sometimes used because they may have fewer side effects than amitriptyline.

  These medications can cause sleepiness, dry mouth, constipation, weight gain and other side effects.

  Another class of antidepressants called selective serotonin reuptake inhibitors hasn’t been proved to be effective for migraine prevention. These drugs may even worsen or trigger headaches.

  However, research suggests that one serotonin and norepinephrine reuptake inhibitor, venlafaxine (Effexor XR), may be helpful in preventing migraines.

• Anti-seizure drugs. Some anti-seizure drugs, such as valproate (Depacon) and topiramate (Topamax), seem to reduce the frequency of migraines.

  In high doses, however, these anti-seizure drugs may cause side effects. Valproate sodium may cause nausea, tremor, weight gain, hair loss and dizziness. Valproate products should not be used in pregnant women or women who may become pregnant.

  Topiramate may cause diarrhea, nausea, weight loss, memory difficulties and concentration problems.

• OnabotulinumtoxinA (Botox). OnabotulinumtoxinA (Botox) has been shown to be helpful in treating chronic migraines in adults.

  During this procedure, onabotulinumtoxinA is injected into the muscles of the forehead and neck. When this is effective, the treatment usually needs to be repeated every 12 weeks.

• Pain relievers. Taking nonsteroidal anti-inflammatory drugs, especially naproxen (Naprosyn), may help prevent migraines and reduce symptoms.

Alternative medicine

Nontraditional therapies may be helpful if you have chronic migraine pain.

• Acupuncture. Clinical trials have found that acupuncture may be helpful for headache pain. In this treatment, a practitioner inserts many thin, disposable needles into several areas of your skin at defined points.
• Biofeedback. Biofeedback appears to be effective in relieving migraine pain. This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses related to stress, such as muscle tension.
• Massage therapy. Massage therapy may help reduce the frequency of migraines. Researchers continue to study the effectiveness of massage therapy in preventing migraines.
• Cognitive behavioral therapy. Cognitive behavioral therapy may benefit some people with migraines. This type of psychotherapy teaches you how behaviors and thoughts affect how you perceive pain.
• Herbs, vitamins and minerals. There is some evidence that the herbs feverfew and butterbur may prevent migraines or reduce their severity, though study results are mixed. Butterbur isn’t recommended because of long-term safety concerns.

  A high dose of riboflavin (vitamin B-2) also may prevent migraines or reduce the frequency of headaches.

  Coenzyme Q10 supplements may decrease the frequency of migraines, but larger studies are needed.

  Due to low magnesium levels in some people with migraines, magnesium supplements have been used to treat migraines, but with mixed results.

  Ask your doctor if these treatments are right for you. Don’t use feverfew, riboflavin or butterbur if you’re pregnant or without first talking with your doctor.