Exploring Potential Treatments for Migraines: A Journey Towards Relief

If you're living with migraines, you know the relentless search for relief. It’s a quest for understanding, for tools, and for strategies that can reclaim your life from the grip of throbbing pain, debilitating nausea, and crushing sensitivity. The good news? The landscape of migraine treatment continually evolves, offering more options than ever. It's no longer a one-size-fits-all approach, but a personalised journey that requires collaboration with your healthcare provider.

At NervousDoc, we aim to empower you with knowledge and support as you navigate your neurological health. Today, we're diving deep into the diverse world of migraine treatments, from acute pain relief to cutting-edge preventives, exploring how they work and how you can work with your doctor to find what’s right for you.

Understanding the Two Pillars of Migraine Treatment

Migraine treatments generally fall into two main categories:

1. Acute (Abortive) Treatments: These are taken during a migraine attack to stop or significantly reduce the pain and associated symptoms. The goal is to provide rapid relief and allow you to resume your daily activities.
2. Preventive (Prophylactic) Treatments: These are taken regularly, often daily or weekly, to reduce the frequency, severity, and duration of migraine attacks. The goal is to lower the overall burden of migraines on your life.

Your treatment plan will likely involve a combination of both, tailored to your unique migraine profile and lifestyle.

Pillar 1: Acute Treatments – Stopping the Attack in Its Tracks

When a migraine strikes, quick and effective relief is paramount. The choice of acute treatment often depends on the severity of the attack and your response.

• Over-the-Counter (OTC) Pain Relievers:
  • NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Medications like ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin can be effective for mild to moderate migraines. They work by reducing inflammation.
  • Paracetamol: While not anti-inflammatory, it can help with pain relief.
  • Combination Medications: Some OTC products combine paracetamol, aspirin, and caffeine (e.g., Excedrin Migraine), which can be more effective for some individuals due to the synergistic effect of caffeine.
  • Important Note: Overuse of OTC pain relievers (more than 2-3 days a week) can lead to medication overuse headache (MOH), also known as rebound headache, which can worsen migraine frequency.
• Triptans (Serotonin Receptor Agonists):
  • Triptans are considered first-line prescription medications for moderate to severe migraines. They target serotonin receptors in the brain, helping to constrict dilated blood vessels and block pain pathways.
  • Examples include sumatriptan (Imitrex), zolmitriptan (Zomig), naratriptan (Amerge), rizatriptan (Maxalt), eletriptan (Relpax), frovatriptan (Frova), and almotriptan (Axert).
  • Administration: Available in various forms, including pills, nasal sprays, and injectables, allowing for rapid onset of action.
  • Side Effects Can include chest tightness, tingling, flushing, and drowsiness. It is not suitable for individuals with certain cardiovascular conditions.
• Ditans (Serotonin 1F Receptor Agonists):
  • A newer class of acute migraine medication, ditans (e.g., lasmiditan - Reyvow) offer an alternative for those who cannot take triptans due to cardiovascular concerns. They specifically target serotonin 1F receptors without causing vasoconstriction.
  • Side Effects: Can cause dizziness and sedation.
• CGRP Receptor Antagonists (Gepants):
  • Another exciting newer class, gepants (e.g., ubrogepant - Ubrelvy, rimegepant - Nurtec ODT), are acute oral medications that block the activity of calcitonin gene-related peptide (CGRP), a neuropeptide involved in migraine pain.
  • Benefits: Rimegepant (Nurtec ODT) is generally well-tolerated and has fewer cardiovascular concerns than triptans. It also has a preventive indication.
• Ergots:
  • Older medications (e.g., ergotamine with caffeine—Cafergot, Migergot; dihydroergotamine—DHE 45, Migranal Nasal Spray) are used for severe migraines. They work by constricting blood vessels and modulating neurotransmitters.
  • Considerations: They can have significant side effects and are generally reserved for those who don't respond to triptans or prolonged attacks, with the risk of medication overuse headache.
• Anti-Nausea Medications:
  • Often prescribed alongside acute pain relievers, medications like ondansetron (Zofran) or metoclopramide (Reglan) can alleviate migraine-associated nausea and vomiting, which can improve the absorption of oral pain medications.

Pillar 2: Preventive Treatments – Reducing the Burden

For individuals experiencing frequent or severe migraines (typically four or more migraine days per month, or significant disability), preventive treatments become essential. The goal is to reduce migraine frequency by at least 50%, lessen their severity, and improve responsiveness to acute therapies.

• Oral Medications (taken daily):
  • Beta-blockers: Commonly used for high blood pressure and heart conditions, these medications (e.g., propranolol, metoprolol) can also reduce migraine frequency.
  • Antidepressants: Certain antidepressants, particularly tricyclic antidepressants (e.g., amitriptyline, nortriptyline) and serotonin-norepinephrine reuptake inhibitors (SNRIs like venlafaxine), can help prevent migraines, even in individuals without depression. This highlights the complex link between migraines and mood disorders, which we discussed in our post on Unravelling the Link Between Depression and Migraines.
  • Anti-seizure Medications: Topiramate (Topamax) and valproate (Depakote) are often effective for migraine prevention, though they can have significant side effects.
  • Blood Pressure Medications: Angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril) and angiotensin receptor blockers (ARBs, e.g., candesartan) are also used for migraine prevention.
• CGRP Monoclonal Antibodies (mAbs):
  • A revolutionary class of preventive medications specifically designed for migraine. These injectable medications (e.g., erenumab - Aimovig, fremanezumab - Ajovy, galcanezumab - Emgality, eptinezumab - Vyepti) target CGRP or its receptor, thus blocking a key pathway involved in migraine generation.
  • Administration: Typically administered via subcutaneous injection (self-administered at home) once a month, once every three months, or intravenously (eptinezumab) every three months.
  • Benefits: Highly targeted, generally well-tolerated with fewer systemic side effects than older oral preventives.
• OnabotulinumtoxinA (Botox):
  • Approved for chronic migraine (15 or more headache days per month, with at least 8 of those being migraine days). Botox injections are given in specific head and neck muscles every 12 weeks.
  • Mechanism: Believed to work by blocking pain signals before they reach the brain.
• Nerve Blocks:
  • Local anaesthetic injections, sometimes with a steroid, around specific nerves (e.g., occipital nerve block) can provide temporary relief. They can be used as a bridge to other preventive treatments or for intractable attacks.
• Neuromodulation Devices:
  • Non-invasive devices that deliver electrical or magnetic pulses to specific nerves. Examples include:
    • Cefaly: A supraorbital transcutaneous stimulator used daily for prevention or during an attack.
    • Nerivio: A remote electrical neuromodulation (REN) device worn on the upper arm for acute treatment.
    • sTMS mini (Transcranial Magnetic Stimulation): A single-pulse transcranial magnetic stimulation device for acute treatment and prevention.
    • gammaCore (Non-invasive Vagus Nerve Stimulation): A non-invasive vagus nerve stimulator for acute treatment and prevention.

Lifestyle Modifications and Complementary Therapies

Beyond medications, holistic approaches play a critical role in migraine management:

• Stress Management: Techniques like mindfulness, meditation, yoga, and deep breathing can significantly reduce migraine frequency.
• Regular Sleep Schedule: Maintaining consistent sleep patterns in duration and timing is crucial.
• Hydration: Dehydration is a common migraine trigger for many.
• Dietary Adjustments: It can be beneficial to identify and avoid individual food triggers (often discovered through a Migraine Diary/Tracking).
• Regular Exercise: Moderate, consistent physical activity can help prevent migraines, but avoid sudden, intense bursts that can trigger attacks.
• Biofeedback: A technique that teaches you to control involuntary bodily functions like heart rate and muscle tension, which can help manage migraine pain.
• Acupuncture: Some individuals find relief from migraine symptoms with acupuncture.

The Collaborative Approach: Working with Your Doctor

Finding the right treatment plan is a process of trial and error, and it requires open communication with your healthcare provider.

• Be Prepared: Bring your migraine diary, a list of all your symptoms, current medications, and any questions you have.
• Be Patient. Finding the most effective treatment or combination of treatments can take time. Don't get discouraged if the first option doesn't work.
• Communicate Side Effects: Be honest about any side effects you experience, as your doctor may need to adjust the dose or switch medications.
• Discuss Your Goals: What does success look like for you? Reducing frequency, severity, or improving your ability to function?

To help your doctor understand the actual impact of your migraines, consider using tools like the MIDAS questionnaire or the HIT-6 to quantify your disability.

Your Journey to Relief Starts Here

Living with migraines can be incredibly challenging, but with the advancements in treatment options and a proactive approach, significant relief is within reach. The key is actively participating in your care, armed with knowledge and supported by your medical team.

Ready to explore more pathways to a life with fewer migraines and greater productivity? Subscribe to NervousDoc.com today! You’ll gain access to our comprehensive resources, expert insights, and a community of individuals who understand your challenges. Let's work together to unlock your potential for a healthier, more productive life.

References:

• Goadsby, P. J., Holland, P. R., & Boes, C. J. (2017). Migraine. The Lancet, 390(10090), 282-293.
• American Academy of Neurology. (2012). Practice Parameter: Pharmacological treatment of migraine prophylaxis. Neurology, 78(17), 1337-1345.
• Silberstein, S. D., Holland, S., Freitag, F., Dodick, D. W., & Argoff, C. E. (2020). Evidence-based guideline update: Pharmacologic treatment for episodic migraine prophylaxis in adults. Neurology, 95(24), 1069-1077.
• Dodick, D. W. (2018). CGRP monoclonal antibodies for the treatment of migraine: a special report from the American Headache Society. Headache: The Journal of Head and Face Pain, 58(Supplement 1), 1-18.