Fight off migraine attacks with powerful prescription treatments

Lifestyle changes can help reduce the frequency of migraine attacks. But there’s an arsenal of prescription medications that can help you avoid or treat the next attack. 

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Reviewed by Dr Yasmin Aghajan, MD

Information last reviewed 07/11/19

About

You should always be evaluated by a medical doctor for an accurate diagnosis of your headaches. There are other dangerous, life threatening neurologic causes of headache that must be distinguished from migraine. This page is not intended to diagnose migraines, but serves as an information reference about what migraines are and how they are treated.

Migraines vs Headaches

Headaches and migraine are both extremely common. There are many different types of headaches, the most common being the “tension” headache almost all people experience in their lives. However, a migraine is a special type of headache, characterized by some classic features or signs. Doctors can diagnose migraines based on symptoms. Neurologists have defined some criteria to help diagnose migraines accurately.

Symptoms of migraine include:

  • Headache lasts between 4 to 72 hours
  • At least two of the following qualities: 
  • One-sided
  • Pulsating
  • Moderate or severe intensity of pain
  • Aggravated by routine activity such as walking or climbing stairs
  • Nausea, vomiting, or both
  • Photophobia (sensitivity to light)
  • Phonophobia (sensitivity to sound)

Some people have migraine with aura, which is characterized by having the above symptoms PLUS vision changes, sensory and/or speech/language symptoms. It is important to speak with a doctor to get the accurate diagnosis for your headaches and to ensure there is not another underlying neurologic problem. 

If you have a headache that you would characterize as the “worst headache of your life,” a significant change in the pattern, frequency, or severity of headaches, new neurologic symptoms (numbness, weakness), headache is always on the same side, headache does not respond to treatment, or you are over the age of 50 and have just started having headaches, have cancer, have HIV, or have symptoms such as cognitive impairment or personality changes, fever or stiff neck you should seek immediate medical attention. 

There are many treatments available for Migraines. They are separated into two categories: Preventative (prevents headaches), and abortive (stops the current headache). Preventive medications include Propranolol and Amitriptyline. Abortive include Sumatriptan (and other medications of the -triptan class), Naproxen, and Acetaminophen. 
 

What are migraines?

Migraine is a common and disabling brain disorder ranked by the World Health Organization (WHO) as the third most prevalent and disabling condition amongst the diseases worldwide under the age of 50. Statistically, women are 2 to 3 times more prone to migraines than men, showing a lifetime prevalence of 33% in women against 13% in men. Around 1 billion people are affected by this disorder worldwide, including 1 in 5 women, 1 in 16 men, and 1 in 11 children. According to the National Institutes of Health (NIH), 12% of Americans suffer from migraine.

Causes

The causes of migraine vary a lot from person to person. However, it is suspected that migraine may be caused by environmental and hormonal changes, as there are recurring reports of migraine triggers linked to lifestyle factors. These include skipped meals, irregular caffeine intake, irregular sleep, and stress. In women, migraine attacks occur more often before and during the menstrual period. Some risk factors for chronic migraine include stressful life events, head injury, excessive consumption of caffeine, overuse of opioids and barbiturates, snoring and sleep apnea, other pain conditions, depression, anxiety, allergic rhinitis, and allodynia (skin and scalp sensitivity to touch).

Symptoms

Migraine can be episodic (occasional attacks) or chronic (symptoms occurring regularly for three months or longer).  It is a disorder characterized by moderate to severe headaches often reported to be pulsing or throbbing (50%), unilateral (60%), and aggravated by head movements and physical activity (90%). As a result of an abnormally sensitive brain, migraine attacks are often accompanied by other symptoms such as neck pain, sinus pain and pressure, extreme sensitivity to light and sound, aura (change in vision such as seeing spots, stars, lines, flashing lights, zigzag lines, or waves), incapacity to concentrate and/or speak, fatigue, mood changes, gastrointestinal symptoms such as nausea and vomiting, dizziness, vertigo, and tinnitus.

Diagnosis

Because the causes of migraine vary a lot from person to person, it is important that patients consult a headache specialist in order to be assessed individually and be given the most adequate and optimal diagnosis and treatment. Many patients who suffer from migraine remain undiagnosed or untreated because of the traditional focus on the severity and intensity of the pain as the primary diagnostic criterion. However, migraine, which is typically associated with severe, unilateral, and throbbing headaches, can also manifest itself under milder forms of pain and, as stated above, be accompanied by other bodily symptoms. As such, a focus on other features of migraine other than headache might be useful in the diagnosis of the condition. Such features might include sensitivity to light and sound, dizziness, fatigue, neck pain, nausea, and inability to function. In the case of chronic migraine, it is very important that patients know exactly how many days a month they experience a headache of any kind. For a proper diagnosis of chronic migraine, it is often advised that patients maintain a daily headache/migraine diary.

Related Conditions

Migraines have been associated with increased risks of several other disorders, including asthma, stroke, anxiety and depression, and other pain disorders.

Treatment

There is currently no cure for migraine, but there are established guidelines to help manage the symptoms. There are 2 established types of treatment perceived as effective: treatment of acute migraine and preventive treatment of migraine. In addition to this, lifestyle and non-medical treatments, as well as symptom management tips, can be useful in preventing and/or alleviating headache.

Treatment of acute migraine

Most patients who suffer from episodic migraines have recourse to acute medications to help relieve mild to moderate pain. Acute medications include analgesics (painkillers), ergotamines, and triptans. Simple analgesics are nonsteroidal anti-inflammatory drugs (NSAID). These are considered non-specific migraine medications as they operate to relieve pain in general, reduce inflammation, and bring down a high temperature. Examples of FDA approved NSAIDs include Ibuprofen, Naproxen, Diclofenac, and Celecoxib.

Ergotamines and triptans, on the other hand, are more migraine-specific medications as they have a direct effect on the pain pathway involved in migraine without effect on any other bodily pain. Triptans work by stimulating a neurotransmitter in the brain called serotonin to reduce inflammation and stop the headache. Examples of FDA approved triptans include Almotriptan, Eletriptan, Frovatriptan, Naratriptan, Rizatriptan, Sumatriptan, and Zolmitriptan. These are most effective when taken early in a migraine attack when the pain is still mild.

It is advised to use medications for acute migraine with moderation as they might cause side effects such as nausea, vomiting, rebound headaches and progression to chronic headache disorders. Often, anti-nausea and other symptom-preventing medications are given alongside the migraine medication to prevent such side effects.

Preventive treatment of migraine

Preventive treatment of migraine is important for patients who suffer from chronic migraine or who are known to be resistant to medications for episodic migraine attacks.

Chronic migraine is defined as headache occurring on more than 15 days per month for more than 3 months, with migraine features on at least 8 of those days. Because an adequate choice of preventive medications depends on many factors such as high blood pressure, asthma, diabetes, or pregnancy, it is essential that the choice of a preventive medication be rightly assessed from individual to individual. 

In the case of preventing episodic migraines, it is generally agreed that preventive treatment is warranted if migraine occurs at least once per week or on 4 or more days per month. Most preventive medications for migraine have been secondarily adopted as treatments for migraine and include blood-pressure medications (beta-blockers, calcium channel blockers), antidepressants (tricyclic antidepressants, selective serotonin reuptake inhibitors), anticonvulsants.

In any case, preventive treatment should be established in consultation with a doctor and not be self-prescribed as it can lead to serious side effects.

Lifestyle and non-medical treatment

There are ways in which patients can help themselves prevent migraine attacks by making lifestyle changes. Maintaining a balanced diet can help to ease and prevent migraine attacks. Some people have reported that their symptoms appear when they eat certain foods, however, these vary from person to person. Frequently reported food triggers include alcohol (especially red wine), artificial sweeteners, caffeine withdrawal, chocolate, processed meats and foods. In addition to this, regular exercise can also help reduce the frequency of migraine attacks since it reduces stress, helps to regulate sleep and combat obesity; all factors which, if kept unregulated, have been linked to migraine attacks. Yoga can be a good start to ease into a regular exercise routine.

Migraine management tips

In the case of a migraine attack, there are several non-medical ways that can help you manage and partially alleviate your symptoms. Many migraine patients report seeking out a dark room where they can lie down, close their eyes and relax. This can help ease the tension. It is generally advised to relax and avoid stress and get good quality sleep. Massaging your neck and temples can also help sooth the tension by improving blood flow. Another way to relieve tension headaches is by applying a heating pad or a warm cloth around your neck.

Comparison Table

Treatment

Type

How it works Efficacy for migraine treatment
Metoclopramide (acute nausea treatment) Anti-nausea medication Inhibits dopamine receptors in the area of the brain responsible for vomiting, thus inhibiting nausea and vomiting. Useful to reduce nausea associated with migraine.
Propranolol (migraine prevention) Beta-blocker (blood pressure reducing medication) Unclear exactly how it prevents migraine, although thought to be related to reducing arterial dilation. In one study, 84% of people taking Propranolol group reported sustained improvement compared with only 32% on placebo.
Topiramate (migraine prevention)

Anti-seizure medication

Although the exact mechanism is not known, it is thought to calm overactive nerve cells in the brain. It inhibits sodium and calcium channels.It also inhibits the excitatory glutamate pathway, while enhancing the inhibitory effect of the GABA pathway (calming). Comparative trials suggest that Topiramate is as effective as Propranolol for episodic migraine prevention, but it is more expensive.
Naproxen (acute migraine treatment) Non-steroidal anti-inflammatory drug (NSAID) As an NSAID, Naproxen inhibits the cyclo-oxygenase (COX-1 and COX-2) pathways which in turn inhibits the pro-inflammatory prostaglandin cascade. This reduces inflammation and pain.  The exact efficacy is unknown, however, some people find good relief with Naproxen for migraines. Overuse can lead to overuse headaches. Naproxen is not to be used to prevent migraine. It is more effective when taken with Sumatriptan than either Sumatriptan or Naproxen alone.
Sumatriptan (acute migraine treatment)

Triptan

Triptans are part of the class of selective serotonin receptor agonists. They work by narrowing blood vessels in the brain, and blocking the release of certain natural substances that cause pain, nausea, and other symptoms of migraine. Some studies show up to 60% of people experience relief with Sumatriptan, although this is variable per person.
Rizatriptan (acute migraine treatment) Triptan Like Sumatriptan, Rizatriptan is a selective serotonin receptor agonist. Rizatriptan is one of the most effective triptans in studies. It has shown about 30-60% efficacy in migraine treatment.
Amitriptyline (migraine prevention) Tricyclic antidepressant Amitriptyline works by increasing levels of serotonin and norepinephrine in the brain, which in turn influence how the brain perceives pain. In one study, over half of patients on amitriptyline had >50% improvement in symptoms, compared to one third of patients on placebo

Q&A

Disclaimer: This is not medical advice. You and your physician will determine if and how you should take any medication prescribed to you following a medical consultation.

  1. American Migraine Foundation, ‘Commonly Used Acute Migraine Treatments’ https://americanmigrainefoundation.org/resource-library/commonly-used-acute-migraine-treatments/ [accessed 5 March 2019]

  2. American Migraine Foundation, ‘Preventive Treatment’ https://americanmigrainefoundation.org/resource-library/understanding-migrainepreventive-treatments/  [accessed 5 March 2019]

  3. Charles, Andrew, ‘Migraine’ in The New England Journal of Medicine, 377:6 (2017), pp. 553-561

  4. Dodick, Daivid W, ‘Migraine’, in Lancet, 391 (2018), pp. 1315-30

  5. National Headache Foundation, ‘Facts About Triptans’ https://headaches.org/2007/11/19/facts-about-triptans/ [accessed 5 March 2019]

  6. National Migraine Centre, ‘Migraine Treatment’ https://www.nationalmigrainecentre.org.uk/migraine-and-headaches/migraine-treatment/  [accessed 4 March 2019]

  7. Stroke Association, ‘Migraine and Stroke’ (2017) https://www.stroke.org.uk/sites/default/files/migraine_and_stroke.pdf [accessed 9 March 2019]

  8. The Migraine Trust, ‘Symptoms and Stages of Migraine’ https://www.migrainetrust.org/about-migraine/migraine-what-is-it/symptoms-and-stages/ [accessed 9 March 2019]

  9. U.S. Food & Drug Administration, Treating Migraines: More Ways to Fight the Pain’ https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm414707.htm /  [accessed 4 March 2019]

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