Introduction
Before you consider any treatment for your headaches, it is important that you make sure your diagnosis is indeed migraine. There are excellent treatments available now for the treatment of most migraine headaches. However, if the diagnosis of your headache is not migraine, or if you have more than one type of headache, as many people often do, then the best migraine therapies will probably not work for you.
As well, there are some less common, but very serious causes for headaches, such as tumors and blood vessel disorders, for example, and it would be wrong to treat these conditions as migraine. Thankfully most migraine headaches are easy to recognize and treat, but I always suggest that if anyone has any doubt about their headaches, then please see your doctor, which is also the best advice if you want to know about various medical treatments. I also believe that it is your job to learn all you can about migraine. The more you know, the better off you and your migraine headaches will be. This article will deal generally with what you should know about treatments for your migraine headaches.
Principles of Treatment
All treatments for migraine have the same treatment goals in common. They are designed to take away your migraine symptoms. The most important symptom you will probably have with your migraine headache is pain, and as you know, the pain can be very severe and last many hours. So virtually all migraine therapies are designed to stop, or at least reduce, pain. It is also important to reduce or take away other significant migraine symptoms, such as nausea and vomiting, which for some people, is more disabling than the pain of migraine. So no matter what treatments you use yourself or are suggested to you by your doctor or other healthcare professionals, you will want to know if it will be effective in reducing your symptoms.
There are general and specific treatments that everybody agrees are helpful for treating or preventing migraine attacks, and there are recognized guidelines for doctors and other healthcare professionals to follow in recommending treatment options for your migraine. However, I believe you have to get the best treatment for your own migraine headaches and often treatment has to be individualized to best meet your needs. All people are different, and I find that each person’s migraine affects them in their own special or unique way. So once again, decide for yourself what is best for you and be prepared to accept and make changes in your treatment as necessary.
What follows is a general overview of treatments. Not all treatments are for everyone and of course, some may work for one person and not another. The following should give you a good idea what you should know. Most important, remember that most medical treatments have benefits and risks, and it is wise to understand the risks in particular, especially if using medications. You do not have to know or understand everything about every treatment or medication, as no one including your doctors can know that much, but you should know what most people would want to know, such as whether there are serious side effects or drug interactions. Your doctor and often your pharmacist are probably the best people to let you know about medications.
Track your headaches and treatments
It is also very important that you keep track of your headaches and their responses to various treatments, especially if you have more than one type of headache or migraine. The best way to do this is by using a diary—one you make up yourself or one you can get from most doctors. Doing so will allow you to keep track of your headaches, how many you are having, and how severe they are, as well as how you treated them. Also, you will be able to see if anything triggers your particular headaches and determine how much time you missed from work. This information is very useful to have when you see your doctor about your headaches and how they respond or do not respond to treatments.
Acute Treatment
There are a lot of things you can do for yourself to help treat each of your migraine headaches. Symptomatic therapy applies to individual migraine attacks. If you know you are going to have one of your typical migraine attacks, then you can start right away to "treat" it. Some people have what is called a prodrome, which is a warning, usually several hours before the main symptoms begin. It is sort of like the "calm before the storm." except during this prodrome some people are tired or excited, feel good or bad, have diarrhea, sleepiness, or start to yawn.
So if the attack is coming, try to get to a dark quiet room, since noise and bright lights seem to aggravate the symptoms of migraine. If there are any smells or odors that trigger your migraine headaches on a regular basis, then get away from them when the attack begins. Also, a cool room is also helpful and lying down to rest or going to sleep can help. Some people find that by falling asleep, they can actually stop the attack. Try putting a cold damp cloth on your forehead or temple (on the side that is painful), or use a frozen bag of peas wrapped in a small towel, as cold compresses can sometimes help with the pain. Some people I know put fingertip pressure on one of your temporal arteries, which are arteries you can feel on either side of your head near your temples. The temporal artery will pulse during a migraine, so the pressure can help reduce the pain. I have some patients who actually tie a soft band around the top of their heads and it works for them, but make sure you do not press too hard or too long, or tie the band too tight!
Acetaminophen and ASA
If the pain is severe, which it frequently is during a full-blown migraine attack, then you may need medication (although some other non-medication treatments can work for some people). If early enough in the attack, then most people try a simple painkiller or analgesic. The most common ones are ASA (aspirin) or acetaminophen (Tylenol). Usually, a moderately severe migraine will require two or three standard-dose pills to provide relief. Rarely do these medications help severe migraine headaches. They are worth a try, but if there is no relief, then you will have to move on to something stronger such as these same medications with the addition of codeine. Again, they may help moderate attacks, but there is a worry that if you take analgesics too often, then you may be causing more headaches for yourself than relieving them; these are called analgesic rebound headaches.
Analgesic use
Limit analgesic usage to regular doses no more than two to three days per week. Also, learn all about their side effects and avoid ASA if you have stomach disease, kidney disease, or a bleeding disorder. Avoid acetaminophen if you have liver disease. There are other cautions with these medications, but your pharmacist should be able to help you with these drugs since you do not need a prescription unless they contain a lot of codeine or other restricted drugs.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Another group of medications that have been most useful in treating mild to moderate migraine headache are the NSAIDs which are non-steroidal anti-inflammatory drugs, which are somewhat like ASA and have similar benefits, risks, and side effects. Ask your pharmacist or doctor about these medications. Further combined analgesic compounds containing ASA or acetaminophen with higher doses of codeine or a barbiturate can be effective in moderate to severe migraine headaches, but must be prescribed by your doctor. Be careful not to overuse these latter medications; they are good friends when you need them, but poor masters!
Ergot compounds
One group of migraine medications that have been used for many decades is the ergot compounds. Ergots work by constricting or narrowing blood vessels that are painful and dilated or enlarged during your migraine attack. They are still used, but have potentially serious side effects and can be misused. They are not as effective as the newer migraine specific medications, but work well for some patients and are generally safe and effective if used properly. If you are using ergot medications on a regular basis, it would be wise to keep in touch with your doctor on a regular basis to ensure you are not having any problems. I rarely prescribe most ergot medications anymore, but I do have patients who use them and do not suffer side effects. I still prescribe DHE (dihydroergotamine), which is one form of ergot medication. It is very effective and can be used by injection or nasal spray, and lacks some of the more powerful blood vessel constrictor properties of the other ergots. It is worth trying for a more severe migraine headache, but you should consult your physician before using it.
Triptans
The newest migraine-specific medications that most people with migraine have tried are the triptans. Triptans, like ergots, also constrict blood vessels during a migraine attack and are also felt to work by possibly stopping the inflammation around these vessels. They also reduce non-pain symptoms such as nausea. The first one produced about ten years ago was sumatriptan. There are three others: naratriptan, zolmitriptan, and rizatriptan, with more on the way. They are very effective, well tolerated, and generally safe. However, because they constrict blood vessels, you cannot use them if you have heart disease, hypertension, or other blood vessel disorders, such as stroke.
The triptans come in various formulations, including pills, nasal sprays, melt tablets, and injections. I have recommended triptans to my patients for years, and when they work, they work very well, and I have yet to see any serious side effects. I must say that these medications are expensive, but studies have shown them to be cost-effective—in other words, you get your money’s worth if they are effective when you use them.
Prevention Medications
It is important to prevent migraine headaches if possible. You have several ways to do so by using medications, non-medication therapies, and of course, by avoiding anything that triggers your migraine headaches. It is best to avoid the big triggers like alcohol, especially red wine, chocolate, lack of sleep, or too much sleep, and missing meals. Also, as noted above, avoid bright lights, loud noises, or any smells that could trigger your headache.
There are some generally accepted reasons why you should consider a prevention or prophylactic medication. For the most part, my patients consider these medications because they are having frequent acute migraine attacks, and the acute treatments do not work well enough or not at all, or some patients cannot take some of the acute treatments because of a medical disorder.
Prophylactic medications are taken on a daily basis even if you do not have a headache, and you probably will also have to take some acute medications as well. You have to be committed to taking these medications for several months and you have to know that they are considered effective if they reduce the number of migraine headaches you have by 50 percent a month. You also must consult your physician to learn their benefits, risks, side effects, and interactions with other medications—just as you should with the acute migraine medications.
The prophylactic medications my patients use on a regular basis are varied and include:
Beta-blockers medications: These are heart pills, but are quite effective for migraine prevention, and work on blood vessels by preventing them from enlarging or dilating when a migraine attack occurs. They are also useful if you have cardiac pain (angina) or high blood pressure.
Calcium channel-blockers medications: These are also heart pills that work in migraine prevention, and can be used in some cardiac conditions as well.
Antidepressant medications: These medications are used for depression (amitriptyline and doxepin) and act as painkillers at low doses. But if you have depression and migraine headaches they can work on both.
Anti-seizure medications: Migraine and seizures share many similarities, although they are different disorders. They both come and go and cause a neurological symptom called an aura (or prodrome), which is similar to some seizures, but longer in duration. If you have migraine and a seizure disorder, then these medications can be helpful for both.
Anti-serotonin medications: These medications work directly on the chemical brain messenger serotonin to prevent migraine. It is felt that migraine headache is caused by changes in serotonin levels in the brain, and that is why anti-serotonin medications work. The new triptans also work on serotonin during an attack.
It is important that you see a doctor if you are taking preventive medications for your migraine headaches. It is your job to learn as much as you can about how these medications work and to monitor your use and response to them. Patients have to play a big role in this part of their treatment, and if you do so, I find things usually work out for the best. You will not be on a preventive medication forever, but maybe for several months; they do not work right away, however, and some may take a few weeks to "kick in." as they say.
Other Treatments
Other non-medication treatments include relaxation training; thermal or electromyographic (EMG) biofeedback, which is electrical activity recorded from small sensors attached to the scalp, combined with relaxation training; and cognitive-behavioral treatments. Most of these treatments are safe and will not harm you or your pocketbook, and they are effective for some patients. They are usually used as preventive treatments and should be done by recognized professionals.
Last Things Last
This brief overview should let you know that there are a lot of treatment options now available for your migraine headaches. Some of you will get spectacular results with one or more of these treatments and others will not. However, it has been my experience and the experience of a large number of my patients that if the treatments work, they work well, are safe and have few problems.
I would encourage you, once again, to learn all you can about migraine and discuss it with your doctor or other health professionals. It really does pay off to learn more, and there is a lot to learn, especially with the new knowledge we have about migraine headache in the past decade.
