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How is a migraine treated?

Dr. Mosaraf Ali, MD
Integrative Medicine Specialist

If you're prone to migraines, you should know about the different treatment options—including some that can help prevent the headache in the first place. To learn more, watch this video.

Treatment of migraines depends on how frequent episodes are. In this video, Adel Olshansky, MD, a neurologist at West Hills Hospital, describes the kinds of medications that doctors will recommend to stop and even prevent the headaches.

Dr. Terry W. Smith, MD
Family Practitioner

Traditional medicines have worked to treat migraines when the patient is having only one or two migraines a month. If you’re having two or three migraines a week, which can be incapacitating, alternative approaches can be beneficial. Sleep hygiene and eight hours of sleep are crucial. Balancing hormones and stress are important. A large percentage of patients with migraines have gluten sensitivity just short of celiac disease and see a significant improvement with going 100 percent gluten free. Also, monosodium glutamate (MSG) is a common additive in a variety foods; avoiding foods that may have MSG in them can be helpful to a lot of patients. A few patients may get migraines from eating cheese and bananas, or drinking wine—avoiding these foods can help as well.

There are two ways to approach the treatment of a migraine headache with drugs: prevent the attacks, or relieve the symptoms during the attacks. Many people use both approaches by taking medications originally developed for epilepsy and depression to prevent future migraine attacks, and treating attacks, when they happen, with drugs called triptans that relieve pain and restore function. Hormone therapy may help some women whose migraines seem to be linked to their menstrual cycle. Stress management strategies, such as exercise, relaxation, biofeedback and other therapies designed to limit discomfort, may also reduce the occurrence and severity of migraine attacks.

This answer is based on source information from the National Institute of Neurological Disorders and Stroke.

Treatment usually first involves avoiding factors known to cause a migraine attack, such as foods, environmental triggers such as perfume and medications such as birth control pills.

Over-the-counter, anti-inflammatory medications (such as aspirin, ibuprofen, etc.) may reduce the severity of an acute attack. Drugs that constrict the blood vessels, including caffeine and ergotamines, are sometimes used.

Also, certain prescription medications that deal directly with the presumed chemical imbalances of migraine are available (including Imitrex®, Amerge®, Maxalt® and Zomig®).

If migraine attacks are severe or frequent enough, medication may be required on a regular basis to prevent migraine. The four most commonly used medication groups are tricyclics, beta-blockers, calcium channel blockers and some anti-seizure medications.

Your ophthalmologist (Eye M.D.) may refer you to a neurologist or another specialist for further tests and evaluation.

The first drugs brought to market to treat migraine headaches, known as ergots, targeted the problem of dilated blood vessels, or vasodilation. Although ergots have long been available in various formulations, trials to test a new, potentially more effective delivery method—inhaling the drug into the lungs—began in 2009. Another promising development for people who hate needles: several drug companies are testing needle-free techniques to deliver triptan drugs (that work by constricting blood vessels in the head) through the skin. The popular wrinkle treatment, Botox, was approved to treat unrelenting pain from the most devastating form of migraine.

To help ease symptoms of a migraine headache, try these home remedies:

  • Lie down, preferably in a dark, quiet room.
  • Place a cold compress (an ice pack, bag of ice cubes, or bag of frozen vegetables, wrapped in a towel) on your head and a heating pad or warm towel on the back of the neck and shoulders.
  • Sip ginger ale to ease nausea and replace any fluids lost from vomiting.
  • If your headache is especially bad, take a medication that makes you drowsy—a sleeping pill or the nonprescription allergy drug diphenhydramine (Benadryl).

Treatments available for migraines:

Biofeedback: Biofeedback is one of the alternative treatments available for a migraine and tension headache that has scientific research to back it up. It is a method that is taught by a specialist, usually a psychologist. Biofeedback helps to control the body’s physical response to pain. At Mount Sinai we have specialists trained in biofeedback for those ages 8 and above.

Onabotulinum toxin A (Botox) injections: OnabotA injections are the only medication currently approved by the FDA for chronic migraine sufferers. The injections are given in the face, head and neck to help reduce the frequency and/or the severity of headaches. The injections are usually given every 12 weeks.

Intravenous infusions: Intravenous infusions are offered in our infusion center. Sometimes a migraine attack does not respond to any of the available medications that are available by mouth and in some cases intravenous medication is needed. We offer an infusion center where intravenous medications can be administered without the need to visit the emergency room. Infusions can be given as a one time dose or can be repeated on subsequent days if needed.

Interventional procedures: Interventional procedures such as supraorbital and occipital nerve blocks where local anesthetic are injected into a superficial nerves in the scalp, radiofrequency ablation a longer lasting procedure where a superficial nerve is heated so that it cannot produce pain signals and occipital nerve stimulators small implanted devices are offered through our pain and neurosurgical specialists. These procedures are usually offered to those with more refractory headaches that have failed multiple different types of medications. While more invasive these procedures can offer a different way to manage pain and can be helpful without the systemic side effects of medications.

Find out the exact diagnosis and details of your treatment plan, says Mark Green, MD, director of the Center for Headache and Pain Medicine at the Mount Sinai School of Medicine. In this video, he offers other suggestions.

Migraine treatment consists of lifestyle changes, preventative and acute medications.

The most important task is to identify the potential migraine triggers, which include certain foods, alcohol, physical exercise, hunger, weather changes, excess caffeine, fluorescent lights. The elimination of these triggers may eliminate the headaches. If the triggers are not identified then the headaches need to be treated with medications.

There are two type of medications used to treat migraines: acute, which are used to stop the migraine attack as it starts developing, and preventative, which serve to reduce the number of headaches. The latter ones are only needed when the headaches occur frequently. For acute treatment both over the counter and prescription medications can be used, while preventative medications are only by prescription.

Migraine headaches severity can worsen if not treated early within the first hour. The later you take your medication the longer it may take for the migraine headache to subside. If you do not get relief from the medications, you should talk to your doctors about this. Some medications are more effective and quicker acting than others.

Relaxation methods and stress management are also very important in the treatment of migraine headaches.

Dr. Dawn Marcus
Neurologist

Treating a migraine during the early headache phase, while symptoms are less severe, can dramatically reduce symptom severity during the later stages of the headache phase and also reduce the duration of the headache phase.

Migraine headache medications can be divided into four categories:

  • Acute therapy: Treats a specific headache episode
  • Prevention therapy: Reduces the frequency and severity of future headaches
  • Nausea treatments: Used to reduce severe nausea and vomiting during a headache
  • Rescue therapy: Taken on those infrequent occasions when other therapies don't work

A good marker for determining when to treat is by monitoring your headache phase for the development of touch sensitivity, which is referred to as cutaneous allodynia. (Cutaneous means skin and allodynia means "different pain" or pain resulting from a normally non-painful action.) In this case, a gentle touch that would not normally be perceived as causing pain is felt as something painful. During a migraine, you may feel cutaneous allodynia in several ways:

  • You may find it uncomfortable to wear jewelry or glasses.
  • You may feel as if your "hair hurts."
  • You may not want people to touch you.

Once you start to feel symptoms of touch sensitivity, typical migraine medications are usually much less effective compared with taking the same medication before the allodynia started.

Well-known headache expert Dr. Richard Lipton recently developed the five-question Migraine Treatment Optimization Questionnaire to determine whether an individual's migraine treatment is working well, as shown below. If you answer "no" to any of the first three questions, you may need to treat your migraine earlier, adjust medication doses or change treatments. If you answer "yes" to all of the questions except the last one, you may wish to add more non-drug therapies to your treatment regimen.

Answer the following questions based on your headaches over the last 4 weeks:

  1. Can you quickly return to normal activities after taking your migraine medication?
  2. Can you usually count on your migraine medication to relieve pain within 2 hours?
  3. Does one dose of medication usually relieve your headache and keep it away for at least 24 hours?
  4. Do you have problems with side effects from your migraine medication?
  5. Are you comfortable enough with your medication to plan your daily activities? 

If you answered "no" to any of them, take this quiz with you to your doctor to talk about ways to improve your treatment.

The Woman's Migraine Toolkit: Managing Your Headaches from Puberty to Menopause (A DiaMedica Guide to Optimum Wellness)

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The Woman's Migraine Toolkit: Managing Your Headaches from Puberty to Menopause (A DiaMedica Guide to Optimum Wellness)

Migraines are a common, controllable type of headache that affects one in every six women, more than 20 million in the United States alone. The Woman’s Migraine Toolkit helps readers take charge of...

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.