Questions and Answers About Migraine Treatments

What types of treatments can I use for the onset of symptoms from a migraine attack? (non-prescription, prescription)

Treatment used at the beginning of migraine symptoms are called acute treatments. These range from over-the counter medications and treatments such as NSAIDs (nonsteroidal anti-inflammatory drugs) like aspirin, ibuprofen and naproxen to acetaminophen, and combination treatments like aspirin/acetaminophen/caffeine to devices and prescription medications.

Some people find ice packs and cold rubs to be helpful during an attack as well. Though there are not many studies that support this, it is common for people with migraine disease to use ice on their head and neck during an attack.

If over-the-counter treatments are not effective, it’s time to speak to your healthcare provider (HCP) about prescription medications.

Neuromodulation devices are a non-medication way to treat a migraine attack after it starts but may still require a prescription. Devices work in different ways to reduce the abnormal signaling in the brain involved during a migraine attack. FDA-cleared devices for acute treatment of migraine prevention include sTNS (Cefaly), remote electrical neuromodulation (Nerivio), sTMS (e-Neura), eCOTs (Relivion) and nVNS (gammaCore).

The most common prescription medication prescribed for migraine is a class known as triptans. These are medications you use as needed for an attack that work on blocking chemicals that are released during the pain phase of a migraine attack. Triptans can be tablets you swallow, tablets that dissolve in your mouth or nasal sprays, and one comes as a self-injection.

The different forms are important because migraine can cause nausea and vomiting. If nausea or feeling like you can’t eat or drink during an attack is common for you, using a medication by nose or by injection is important. Triptans should not be used more than 10 days a month or they can cause something known as rebound headache or medication overuse headaches (MOH). They also do not work well late in a migraine attack.

Another category of acute treatment are gepants. Gepants are also used specifically for migraine attacks and can be taken as a tablet, an oral dissolvable tablet or a nasal spray. They have fewer side effects than triptans and can be used in a wider range of populations, but they may not be as effective as triptans for some people. Gepants block a protein called CGRP that is involved in what can bring on a migraine attack. One gepant has been shown to work if taken during the prodrome phase or aura (before the pain of migraine starts). Gepants are not thought to cause rebound headache and can be beneficial for those with more frequent attacks.

A third category of acute treatment are ergots. Ergots block a wider number of chemicals involved in migraine, so they can sometimes be effective when other treatments are not. Ergots can be taken as a nasal spray or injection and can work early or later in a migraine attack.

Are there treatments available to prevent migraines? (non-prescription, prescription)

To reduce the frequency of migraine attacks and improve disability, preventive treatment is used. Preventive treatment includes behavioral therapies, vitamin supplements, neuromodulation devices and medications that can be prescribed by your clinician.

For all people with migraine, lifestyle changes should be considered. These include:

• Regular sleep and wake schedules
• Regular eating times
• Good hydration with water — drink water when you are thirsty
• Regular exercise — move your body every day even if you’re having a headache attack. Try stretching in place or holding a gentle yoga pose.
• Regulate stress — meditate, practice deep breathing, get regular exercise and movement, journal, listen to calming music, step away from negative situations

Behavioral interventions can be used alone or in addition to medication to help reduce migraine frequency. The best studied behavioral techniques to reduce frequent migraine attacks include biofeedback, progressive muscle relaxation and cognitive behavioral therapy if you’re experiencing generalized anxiety or anxiety about your migraine attacks or struggling to cope with chronic pain.There are other types of intervention that are being studied, including mindfulness and acceptance and commitment therapy.

Vitamin supplements that have good evidence for migraine prevention include riboflavin, magnesium and butterbur. Butterbur should be used under the instruction of an HCP because using the wrong type may be dangerous for your liver health. There are other supplements used for migraine prevention, but the studies are not as strong that they are effective.

Many medications are available to prevent migraine. There are migraine-specific treatments that block CGRP, which is a protein involved in causing migraine. Tablets that block CGRP can be given daily or every other day. Injections of monoclonal antibodies that block CGRP can be given monthly or every three months. Tablets can be easier for some people to take, but a monthly or quarterly injection may be more convenient. To make a decision about what medication may be best for you, it’s a good idea to have a conversation with your HCP and review potential side effects.

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There are also medications that are older and inexpensive because they have been around for decades that have been found to be effective in reducing migraine frequency. These include some blood pressure medications, some anti-seizure medications and a few specific antidepressants.

For people with chronic migraine (more than 15 migraine days per month for three months, where eight headache days have migraine characteristics), injections with onabotulinumtoxin A (Botox) is an FDA-approved treatment option as well. A trained injector follows a specific injection protocol to give the treatment every 12 weeks to reduce migraine frequency and disability.

Finally, there are the neuromodulation devices mentioned above.

When should I consider using preventive therapy?

If you have six or more migraine attacks per month, you should consider starting preventive therapy.

You should also discuss preventive therapy with your HCP if you have two or more migraine attacks per month and you’re missing work or life events, you don’t have a good acute treatment that works for attacks, or you have attacks associated with severe symptoms (such as muscle weakness during the migraine attack).

Are there any alternative therapies, such as cognitive behavioral therapy (CBT), acupuncture, or biofeedback, that I should consider?

There is a body of evidence that biofeedback reduces the number of migraine attacks people experience and how bad their migraine attacks are compared to people who are not taking medication, but the evidence does not show that it helps more than medication or CBT, which also has robust evidence supporting its effectiveness. Acupuncture has mixed evidence, but I do recommend that patients who are interested (and can afford the cost and the time off work) give it a try because it can help reduce attack frequency.

Should I go to a headache specialist? How can I find one?

A good place to start treatment is with your primary care provider or a general neurologist, as there are very few headache specialists in the U.S. If you feel you are not improving or have multiple types of headache disorders or conditions that go along with your headache attacks, then a headache specialist would be the next step.

To find a headache specialist certified in headache medicine, you can search the United Council of Neurological Subspecialty directory.