Medical Editors: Harley I. Kornblum, MD, PhD, Jay W. Marks, MD
- What is a migraine headache?
- What are the symptoms of migraine headaches?
- How is a migraine headache diagnosed?
- How are migraine headaches treated?
- What is the treatment for moderate to severe migraine headaches?
- What other medications are used for treating migraine headaches?
- How are migraine headaches prevented?
- What are migraine triggers?
- What should migraine sufferers do?
- What are prophylactic medications for migraine headaches?
- What is the proper way to use preventive medications?
- What is the treatment for menstrual migraine?
- Conclusions
- Headache & Migraine Triggers - Slideshow
- Patient Discussions: Migraine Headache - Effective Treatments
Migraine Pain:
What to Do About It
How Not to Suffer from Migraine Pain
- Go to sleep and waking up at the same time each day.
- Exercise regularly (daily if possible). Make a commitment to exercise even when traveling or during busy periods at work. Exercise can improve the quality of sleep and reduce the frequency and severity of migraine headaches. Build up your exercise level gradually. Over-exertion, especially for someone who is out of shape, can lead to migraine headaches.
- Do not skip meals, and avoiding prolonged fasting.
- Limit stress through regular exercise and relaxation techniques.
- Limit caffeine consumption to less than two caffeine-containing beverages a day.
- Avoid bright or flashing lights and wearing sunglasses if sunlight is a trigger.
- Identify and avoid foods that trigger headaches by keeping a headache and food diary. Review the diary with your doctor. It is impractical to adopt a diet that avoids all known migraine triggers, however, it is reasonable to avoid foods that consistently trigger migraine headaches.
What is a migraine headache?
A migraine headache is a form of vascular headache. Migraine headache is caused by a combination of vasodilatation (enlargement of blood vessels) and the release of chemicals from nerve fibers that coil around the blood vessels. During a migraine attack, the temporal artery enlarges. (The temporal artery is an artery that lies on the outside of the skull just under the skin of the temple.) Enlargement of the temporal artery stretches the nerves that coil around the artery and causes the nerves to release chemicals. The chemicals cause inflammation, pain, and further enlargement of the artery. The increasing enlargement of the artery magnifies the pain.
Migraine attacks commonly activate the sympathetic nervous system in the body. The sympathetic nervous system is often thought of as the part of the nervous system that controls primitive responses to stress and pain, the so-called "fight or flight" response. The increased sympathetic nervous activity in the intestine causes nausea, vomiting, and diarrhea. Sympathetic activity also delays emptying of the stomach into the small intestine and thereby prevents oral medications from entering the intestine and being absorbed. The impaired absorption of oral medications is a common reason for the ineffectiveness of medications taken to treat migraine headaches. The increased sympathetic activity also decreases the circulation of blood, and this leads to pallor of the skin as well as cold hands and feet. The increased sympathetic activity also contributes to the sensitivity to light and sound sensitivity as well as blurred vision.
Migraine afflicts 28 million Americans, with females suffering more frequently (17%) than males (6%). Missed work and lost productivity from migraine create a significant public burden. Nevertheless, migraine still remains largely undertreated and underdiagnosed. Less than half the sufferers are diagnosed by their doctors.
What are the symptoms of migraine headaches?
Migraine is a chronic condition of recurrent attacks. Most (but not all) migraine attacks are associated with headaches. Migraine headaches usually are described as an intense, throbbing or pounding pain that involves one temple. (Sometimes the pain can be located in the forehead, around the eye, or the back of the head). The pain usually is unilateral (on one side of the head), although about a third of the time the pain is bilateral. The unilateral headaches typically change sides from one attack to the next. (In fact, unilateral headaches that always occur on the same side should alert the doctor to consider a secondary headache, for example, one caused by a brain tumor). A migraine headache usually is aggravated by daily activities like walking upstairs. Nausea, vomiting, diarrhea, facial pallor, cold hands, cold feet, and sensitivity to light and sound commonly accompany migraine headaches. As a result of this sensitivity to light and sound, migraine sufferers usually prefer to lie in a quiet, dark room during an attack. A typical attack lasts between 4 and 72 hours.
An estimated 40%-60% of migraine attacks are preceded by premonitory (warning) symptoms lasting hours to days. The symptoms may include sleepiness, irritability, fatigue, depression or euphoria, yawning, and cravings for sweet or salty foods. Patients and their family members usually know that when they observe these warning symptoms that a migraine attack is beginning.
An estimated 20% of migraine headaches are associated with an aura. Usually, the aura precedes the headache, although occasionally it may occur simultaneously with the headache. The most common auras are 1) flashing, brightly colored lights in a zigzag pattern (fortification spectra), usually starting in the middle of the visual field and progressing outward and 2) a hole (scotoma) in the visual field, also known as a blind spot. Some elderly migraine sufferers may experience only the visual aura without the headache. A less common aura consists of pins-and-needles sensations in the hand and the arm on one side or pins-and-needles sensations around the mouth and the nose on the same side. Other auras include auditory (hearing) hallucinations and abnormal tastes and smells.
Complicated migraines are migraines that are accompanied by neurological dysfunction. The part of the body that is affected by the dysfunction is determined by the part of the brain that is responsible for the headache. Vertebrobasilar migraines are characterized by dysfunction of the brainstem (the lower part of the brain that is responsible for automatic activities like consciousness and balance). The symptoms of vertebrobasilar migraines include fainting as an aura, vertigo (dizziness in which the environment seems to be spinning) and double vision. Hemiplegic migraines are characterized by paralysis or weakness of one side of the body, mimicking a stroke. The paralysis or weakness is usually temporary, but sometimes it can last for days.
For approximately 24 hours after a migraine attack, the migraine sufferer may feel drained of energy and may experience a low-grade headache along with sensitivity to light and sound. Unfortunately, some sufferers may have recurrences of the headache during this period.
How is a migraine headache diagnosed?
Migraine headaches are usually diagnosed when the symptoms described above are present. Migraine generally begins in childhood to early adulthood. While migraines can first occur in an individual beyond the age of fifty, advancing age makes other types of headaches more likely. A family history is usually present, suggesting a genetic predisposition in migraine sufferers. In addition to diagnosing migraine from the clinical presentation there is usually an accompanying normal examination.
Patients with the first headache ever, worst headache ever, or where there is a significant change in headache or the presence of nervous system symptoms, like visual or hearing or sensory loss, may require additional tests. The tests may include blood testing, brain scanning (either CT or MRI), and a spinal tap.
How are migraine headaches treated?
Treatment is can include non-medication and medication approaches.
Non-medication therapies for migraine
Therapy that does not involve medications can provide symptomatic and preventative therapy. Using ice, biofeedback, and relaxation techniques may be helpful at stopping an attack once it has started. If possible, sleep is the best medicine. Preventing migraine takes motivation for the patient to make some life changes. Patients are educated as to triggering factors that can be avoided. These include smoking cessation, avoiding certain foods especially those high in tyramine (sharp cheeses) or those containing sulphites (wines) or nitrates (nuts, pressed meats). Generally, leading a healthy life style with good nutrition, adequate water intake, sufficient sleep and exercise may be useful. Acupuncture has been suggested to be a useful non-medication therapy.
Medication therapies for migraine
Individuals with occasional mild migraine headaches that do not interfere with daily activities usually medicate themselves with over-the-counter (OTC, non-prescription) pain relievers (analgesics). Many OTC analgesics are available. OTC analgesics have been shown to be safe and effective for short-term relief of headache (as well as muscle aches, pains, menstrual cramps , and fever) when used according to the instructions on their labels.
There are two major classes of OTC analgesics: acetaminophen (Tylenol) and non-steroidal anti-inflammatory drugs (NSAIDs). The two types of NSAIDs are aspirin and non-aspirin. Examples of non-aspirin NSAIDs are ibuprofen (Advil, Nuprin, Motrin IB, and Medipren) and naproxen (Aleve). Some NSAIDs are available by prescription only. Prescription NSAIDs are usually prescribed to treat arthritis and other inflammatory conditions such as bursitis, tendonitis, etc. The difference between OTC and prescription NSAIDs may only be the amount of the active ingredient contained in each pill. For example, OTC naproxen (Aleve) contains 220 mg of naproxen per pill, whereas prescription naproxen (Naprosyn) contains 375 or 500 mg of naproxen per pill.
Acetaminophen reduces pain and fever by acting on pain centers in the brain. Acetaminophen is well tolerated and generally is considered easier on the stomach than NSAIDs. However, acetaminophen can cause severe liver damage in high (toxic) doses or if used on a regular basis over extended periods of time. In individuals who regularly consume moderate or large amounts of alcohol, acetaminophen can cause serious damage to the liver in lower doses that usually are not toxic. Acetaminophen also can damage the kidneys when taken in large doses. Therefore, acetaminophen should not be taken more frequently or in larger doses than recommended on the label. For information, please read the Acetaminophen and Liver Damage article.
NSAIDs relieve pain by reducing the inflammation that causes the pain (They are called non-steroidal anti-inflammatory drugs or NSAIDs because they are different from corticosteroids such as prednisone, prednisolone, and cortisone which also reduce inflammation). Corticosteroids, though valuable in reducing inflammation, have predictable and potentially serious side effects, especially when used long-term. NSAIDs do not have the same side effects that corticosteroids have.
Aspirin, Aleve, Motrin, and Advil all are NSAIDs and are similarly effective in relieving pain and fever. The main difference between aspirin and non-aspirin NSAIDs is their effect on platelets. Platelets are small particles in the blood that cause blood clots to form. Aspirin prevents the platelets from forming blood clots. Therefore, aspirin can increase bleeding by preventing blood from clotting though it also can be used therapeutically to prevent clots from causing heart attacks and strokes. The non-aspirin NSAIDs also have anti-platelet effects, but their anti-platelet action does not last as long as aspirin.
Aspirin, acetaminophen, and caffeine also are available combined in OTC analgesics for the treatment of headaches. Examples of such combination analgesics are Pain-aid, Excedrin, Fioricet, and Fiorinal.
Finding an effective analgesic or analgesic combination often is a process of trial and error because individuals respond differently to different analgesics. In general, a person should use the analgesic that has worked in the past. This will increase the likelihood that an analgesic will be effective and decrease the risk of side effects.
There are several precautions that should be observed with OTC analgesics:
- Children and teenagers should not use aspirin for the treatment of headaches, other pain, or fever, because of the risk of developing Reye's Syndrome, a life-threatening neurological disease that can lead to coma and even death.
- Patients with balance disorders or hearing difficulties should avoid using aspirin because aspirin may aggravate these conditions.
- Patients taking blood thinners such as warfarin (Coumadin) should not take aspirin and non-aspirin NSAIDs without a doctor's supervision because they add further to the risk of bleeding that is caused by the blood thinner.
- Patients with active ulcers of the stomach and duodenum should not take aspirin and non-aspirin NSAIDs because they can increase the risk of bleeding from the ulcer and impair healing of the ulcer.
- Patients with advanced liver disease should not take aspirin and non-aspirin NSAIDs because they may impair kidney function. Deterioration of kidney function in these patients can lead to rapid and life-threatening deterioration of their liver disease.
- Patients should not overuse OTC or prescription analgesics. Overuse of analgesics can lead to the development of tolerance (increasing ineffectiveness of the analgesic) and rebound headaches (return of the headache as soon as the effect of the analgesic wears off, usually in the early morning hours). Thus, overuse of analgesics can lead to a vicious cycle of more and more analgesics for headaches that respond less and less to treatment and occur more frequently.
What is the treatment for moderate to severe migraine headaches?
Migraine-specific abortive medications usually are necessary for moderate to severe migraine headaches. The abortive medications for moderate or severe migraine headaches are different than OTC analgesics. Instead of relieving pain, they abort headaches by counteracting the cause of the headache, dilation of the temporal arteries. In fact, they cause narrowing of the arteries. Examples of migraine-specific abortive medications are the triptans and ergot preparations.
Triptans
The triptans attach to serotonin receptors on the blood vessels and nerves and thereby reduce inflammation and constrict the blood vessels. This stops the headache. The triptan with the longest history of use is sumatriptan (Imitrex). Sumatriptan is available in the United States as an injection, oral tablet, and nasal spray. Zolmitriptan (Zomig) and rizatriptan (Maxalt) are newer triptans that are available as oral tablets and as tablets that melt in the mouth. Naratriptan (Amerge), almotriptan (Axert) and frovatriptan (Frovalan) are available only as oral tablets.
Traditionally, triptans were prescribed for moderate or severe migraines after OTC analgesics and other simple measures failed. Newer studies suggest that triptans can be used as the first treatment for patients with migraines that are causing disability. (Significant disability is defined as more than 10 days of at least 50% disability during a three-month period.). Triptans should be used early after the migraine begins, before the onset of pain or when the pain is mild. Using a triptan early in an attack increases its effectiveness, reduces side effects, and decreases the chance of recurrence of another headache during the following 24 hours. Used early, triptans can be expected to abort more than 80% of migraine headaches within 2 hours.
Side effects of triptans
The most common side effects of triptans are facial flushing, tingling of the skin, and a sense of tightness around the chest and throat. Other less common side effects include drowsiness, fatigue, and dizziness. These side effects are short-lived and are not considered serious.
The most serious side effects of triptans are heart attacks and strokes. Triptans are effective in migraine headaches because they narrow arteries in the head; however, they also can narrow arteries in the heart. In individuals without existing carotid or coronary artery disease, the narrowing caused by triptans usually does not cause problems. However, in patients whose carotid and coronary arteries are narrowed by atherosclerosis or who suffer from intermittent spasm of the coronary arteries (a condition called Prinzmetal's or variant angina), the narrowing caused by triptans can further reduce the flow of blood through the arteries and have been reported to cause heart attacks and strokes. Therefore, triptans should not be given to patients who have had heart attacks and strokes, or to patients who have symptoms of atherosclerosis such as angina, transient ischemic attack (TIAs), and intermittent claudication.
Healthy adults may have atherosclerosis and narrowing of the coronary arteries that are "silent", that is, without past strokes, transient ischemic attacks, heart attacks, or angina. Therefore, before prescribing a triptan, a doctor should evaluate patients for possible atherosclerosis if they have one or more risk factors for developing atherosclerosis. These risk factors include cigarette smoking, diabetes mellitus, high blood pressure, high levels of LDL ("bad") cholesterol in the blood, obesity, male and over 40 years of age, female and postmenopausal, or a family member(s) who have had heart attacks at an early age. Some patients who are at risk should receive their first dose of a triptan in the doctor's office while being monitored with an electrocardiogram (EKG).
Triptans can interact with other drugs. For example, there have been rare reports of triptans causing a "serotonin syndrome" when given together with a selective serotonin reuptake inhibitor. Selective serotonin reuptake inhibitors (SSRIs) are a class of medications widely used to treat depression. The symptoms of serotonin syndrome include confusion, fever, tremor, high blood pressure, diarrhea, and sweating. Certain triptans such as sumatriptan, zolmitriptan, and rizatriptan can interact with monoamine oxidase inhibitors. Propranolol (Inderal) can raise rizatriptan blood levels. Cimetidine (Tagamet) can increase zolmitriptan blood levels.
Triptans should not be used in pregnant women and are not generally used in young children.
Ergots
Ergots, like triptans, are medications that abort migraine headaches. Examples of ergots include ergotamine preparations (Ergomar, Wigraine, and Cafergot) and dihydroergotamine preparations (Migranal, DHE-45). Ergots, like triptans, cause constriction of blood vessels, but ergots tend to cause more constriction of vessels in the heart and other parts of the body than the triptans, and their effects on the heart are more prolonged than the triptans. Therefore, they are not as safe as the triptans. The ergots also are more prone to cause nausea and vomiting than the triptans. The ergots can cause prolonged contraction of the uterus and miscarriages in pregnant women.
Midrin
Midrin is used to abort migraine and tension headaches. It is a combination of isometheptene (a blood vessel constrictor), acetaminophen (a pain reliever), and dichloralphenazone (a mild sedative). It is most effective if used early during a headache; however, because of its potent blood vessel constricting effect, it should not be used in patients with high blood pressure, kidney disease, glaucoma, atherosclerosis, liver disease, or taking monoamine oxidase inhibitors.
What other medications are used for treating migraine headaches?
Narcotics and butalbital-containing medications sometimes are used to treat migraine headaches; however, these medications are potentially addicting and are not used as initial treatment. They are sometimes used for patients whose headaches fail to respond to OTC medications but who are not candidates for triptans either due to pregnancy or the risk of heart attack and stroke.
In patients with severe nausea, a combination of a triptan and an anti-nausea medication, for example, prochlorperazine (Compazine) or metoclopramide (Reglan) may be used. When nausea is severe enough that oral medications are impractical, intravenous medications such as DHE-45 (dihydroergotamine), prochlorperazine (Compazine), and valproate (Depacon) are useful.
How are migraine headaches prevented?
There are two ways to prevent migraine headaches: 1) by avoiding factors ("triggers") that cause the headaches, and 2) by preventing headaches with medications (prophylactic medications). Neither of these preventive strategies is 100% effective. The best one can hope for is to reduce the frequency of headaches.
What are migraine triggers?
A migraine trigger is any factor that causes a headache in individuals who are prone to develop headaches. Only a small proportion of migraine sufferers, however, clearly can identify triggers. Examples of triggers include stress, sleep disturbances, fasting, hormones, bright or flickering lights, odors, cigarette smoke, alcohol, aged cheeses, chocolate, monosodium glutamate, nitrites, aspartame, and caffeine. For some women, the decline in the blood level of estrogen during the onset of menstruation is a trigger for migraine headaches. The interval between exposure to a trigger and the onset of headache varies from hours to two days. Exposure to a trigger does not always lead to a headache. Conversely, avoidance of triggers cannot completely prevent headaches. Different migraine sufferers respond to different triggers, and any one trigger will not induce a headache in every person who has migraine headaches.
Sleep and migraine
Disturbances such as sleep deprivation, too much sleep, poor quality of sleep, and frequent awakening at night are associated with both migraine and tension headaches, whereas improved sleep habits have been shown to reduce the frequency of migraine headaches. Sleep also has been reported to shorten the duration of migraine headaches.
Fasting and migraine
Fasting possibly may precipitate migraine headaches by causing the release of stress-related hormones and lowering blood sugar. Therefore, migraine sufferers should avoid prolonged fasting.
Bright lights and migraine
Bright lights and other high intensity visual stimuli can cause headaches in healthy subjects as well as patients with migraine headaches, but migraine patients seem to have a lower than normal threshold for light-induced pain. Sunlight, television, and flashing lights all have been reported to precipitate migraine headaches.
Caffeine and migraine
Caffeine is contained in many food products (cola, tea, chocolates, coffee) and OTC analgesics. Caffeine in low doses can increase alertness and energy, but caffeine in high doses can cause insomnia, irritability, anxiety, and headaches. The over-use of caffeine-containing analgesics causes rebound headaches. Furthermore, individuals who consume high levels of caffeine regularly are more prone to develop withdrawal headaches when caffeine is stopped abruptly.
Chocolate, wine, tyramine, MSG, nitrites, aspartame and migraine
Chocolate has been reported to cause migraine headaches, but scientific studies have not consistently demonstrated an association between chocolate consumption and headaches. Red wine has been shown to cause migraine headaches in some migraine sufferers, but it is not clear whether white wine also will cause migraine headaches. Tyramine (a chemical found in cheese, wine, beer, dry sausage, and sauerkraut) can precipitate migraine headaches, but there is no evidence that consuming a low-tyramine diet can reduce migraine frequency. Monosodium glutamate (MSG) has been reported to cause headaches, facial flushing, sweating, and palpitations when consumed in high doses on an empty stomach. This phenomenon has been called Chinese restaurant syndrome. Nitrates and nitrites (chemicals found in hotdogs, ham, frankfurters, bacon and sausages) have been reported to cause migraine headaches. Aspartame, a sugar-substitute sweetener found in diet drinks and snacks, has been reported to trigger headaches when used in high doses for prolonged periods.
Female hormones and migraine
Some women who suffer from migraine headaches experience more headaches around the time of their menstrual periods. Other women experience migraine headaches only during the menstrual period. The term "menstrual migraine" is used mainly to describe migraines that occur in women who have almost all of their headaches from two days before to one day after their menstrual periods. Declining levels of estrogen at the onset of menses is likely to be the cause of menstrual migraines. Decreasing levels of estrogen also may be the cause of migraine headaches that develop among users of birth control pills during the week that estrogens are not taken.
What should migraine sufferers do?
Individuals with mild and infrequent migraine headaches that do not cause disability may require only OTC analgesics. Individuals who experience several moderate or severe migraine headaches per month or whose headaches do not respond readily to medications should avoid triggers and consider modifications of their life-style. Life-style modifications for migraine sufferers include:
- Go to sleep and waking up at the same time each day.
- Exercise regularly (daily if possible). Make a commitment to exercise even when traveling or during busy periods at work. Exercise can improve the quality of sleep and reduce the frequency and severity of migraine headaches. Build up your exercise level gradually. Over-exertion, especially for someone who is out of shape, can lead to migraine headaches.
- Do not skip meals, and avoiding prolonged fasting.
- Limit stress through regular exercise and relaxation techniques.
- Limit caffeine consumption to less than two caffeine-containing beverages a day.
- Avoid bright or flashing lights and wearing sunglasses if sunlight is a trigger.
- Identify and avoid foods that trigger headaches by keeping a headache and food diary. Review the diary with your doctor. It is impractical to adopt a diet that avoids all known migraine triggers, however, it is reasonable to avoid foods that consistently trigger migraine headaches.
What are prophylactic medications for migraine headaches?
Prophylactic medications are medications taken daily to reduce the frequency and duration of migraine headaches. They are not taken once a headache has begun. There are several classes of prophylactic medications: beta blockers, calcium-channel blockers, tricyclic antidepressants, antiserotonin agents and anticonvulsants. Medications with the longest history of use are propranolol (Inderal), a beta blocker, and amitriptyline (Elavil), an antidepressant. When choosing a prophylactic medication for a patient the doctor must take into account the drug side effects, drug-drug interactions, and co-existing conditions such as diabetes, heart disease, and high blood pressure.
Beta blockers
Beta-blockers are a class of drugs that block the effects of beta-adrenergic substances such as adrenaline (epinephrine). By blocking the effects of adrenaline, beta-blockers relieve stress on the heart by slowing the rate at which the heart beats. Beta-blockers have been used to treat high blood pressure, angina, certain types or tremors, stage fright, and abnormally fast heart beats (palpitations). They also have become important drugs for improving survival after heart attacks. Beta-blockers have been used for many years to prevent migraine headaches.
It is not known how beta-blockers prevent migraine headaches. It may be by decreasing prostaglandin production, though it also may be through their effect on serotonin or a direct effect on arteries. The beta-blockers used in preventing migraine headaches include propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor, Lopressor LA, Toprol XL), nadolol (Corgard), and timolol (Blocadren).
Beta-blockers generally are well-tolerated. They can aggravate breathing difficulties in patients with asthma, chronic bronchitis, or emphysema. In patients who already have slow heart rates (bradycardias) and heart block (defects in electrical conduction within the heart), beta-blockers can cause dangerously slow heartbeats. Beta-blockers can aggravate symptoms of heart failure. Other side effects include drowsiness, diarrhea, constipation, fatigue, decrease in endurance, insomnia, nausea, depression, dreaming, memory loss, impotence.
Tricyclic antidepressants
Tricyclic antidepressants (TCAs) prevent migraine headaches by altering the neurotransmitters, norepinephrine and serotonin, that the nerves of the brain use to communicate with one another. The tricyclic antidepressants that have been used in preventing migraine headaches include amitriptyline (Elavil), nortriptyline (Pamelor, Aventyl), doxepin (Sinequan), imipramine (Tofranil), and protriptyline.
The most commonly encountered side effects associated with TCAs are fast heart rate, blurred vision, difficulty urinating, dry mouth, constipation, weight gain or loss, and low blood pressure when standing.
TCAs should not be used with drugs that inhibit monoamine oxidase such as isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), and procarbazine (Matulane), since high fever, convulsions and even death may occur. TCAs are used with caution in patients with seizures, since they can increase the risk of seizures. TCAs also are used with caution in patients with enlargement of the prostate because they can make urination difficult. TCAs can cause elevated pressure in the eyes of some patients with glaucoma. TCAs can cause excessive sedation when used with other medications that slow the brain's processes, such as alcohol, barbiturates, narcotics, and benzodiazepines, e.g. lorazepam (Ativan), diazepam (Valium), temazepam (Restoril), oxazepam (Serax), clonazepam (Klonopin), zolpidem (Ambien). Epinephrine should not be used with amitriptyline, since the combination can cause severe high blood pressure
Antiserotonin medications
Methysergide (Sansert) prevents migraine headaches by constricting blood vessels and reducing inflammation of the blood vessels. Methylergonovine is related chemically to methysergide and has a similar mechanism of action. They are not widely used because of their side effects. The most serious side effect of methysergide is retroperitoneal fibrosis (scarring of tissue around the ureters that carry urine from the kidneys to the bladder). Retroperitoneal fibrosis, though rare, can block the ureters and cause backup of urine into the kidneys. Backup of urine into the kidneys can cause back and flank (the side of the body between the ribs and hips) pain and ultimately can lead to kidney failure. Methysergide also has been reported to cause scarring around the lungs that can lead to chest pain, and shortness of breath.
Calcium channel blockers
Calcium channel blockers (CCBs) are a class of drugs that block the entry of calcium into the muscle cells of the heart and the arteries. By blocking the entry of calcium, CCBs reduce contraction of the heart muscle, decrease heart rate, and lower blood pressure. CCBs are used for treating high blood pressure, angina, and abnormal heart rhythms (e.g., atrial fibrillation). CCBs also appear to block a chemical within nerves, called serotonin, and have been used occasionally to prevent migraine headaches. The CCBs used in preventing migraine headaches are diltiazem (Cardizem, Dilacor, Tiazac), verapamil (Calan, Verelan, Isoptin), and nimodipine.
The most common side effects of CCBs are constipation, nausea, headache, rash, edema (swelling of the legs with fluid), low blood pressure, drowsiness, and dizziness. When diltiazem or verapamil are given to individuals with heart failure, symptoms of heart failure may worsen because these drugs reduce the ability of the heart to pump blood. Verapamil and diltiazem may reduce the elimination and increase the blood levels of carbamazepine (Tegretol), simvastatin (Zocor), atorvastatin (Lipitor), and lovastatin (Mevacor). This can lead to toxicity from these drugs.
Anticonvulsants
Anticonvulsants (antiseizure medications) also have been used to prevent migraine headaches. Examples of anticonvulsants that have been used are valproic acid, phenobarbital, gabapentin, and topiramate. It is not known how anticonvulsants work to prevent migraine headaches.
Who should consider prophylactic medications to prevent migraine headaches?
Not all migraine sufferers need prophylactic medications; individuals with mild or infrequent headaches that respond readily to abortive medications do not need prophylactic medications. Individuals who should consider prophylactic medications are those who:
- Require abortive medications for migraine headaches more frequently than twice weekly.
- Have two or more migraine headaches a month that do not respond readily to abortive medications.
- Have migraine headaches that are interfering substantially with their quality of life and work.
- Cannot take abortive medications because of heart disease, stroke, or pregnancy, or cannot tolerate abortive medications because of side effects.
How effective are prophylactic medications?
Prophylactic medications can reduce the frequency and duration of migraine headaches but cannot be expected to eliminate migraine headaches completely. The success rate of most prophylactic medications is approximately 50%. Success in preventing migraine headaches is defined as more than a 50% reduction in the frequency of headaches. Prophylactic medications usually are begun at a low dose that is increased slowly in order to minimize side effects. Individuals may not notice a reduction in the frequency, severity, or duration of their headaches for 2-3 months after starting treatment.
What is the proper way to use preventive medications?
- Doctors familiar with the treatment of migraine headaches should prescribe preventive medications.
- Decisions about which preventive medication to use are based on the side effects of the medication and the medical conditions that the patient may have.
- Propranolol (Inderal) often is used first, provided that the patient does not have asthma, COPD or heart disease. Amitriptyline (Elavil) also is used commonly.
- Preventive medications are begun at low doses and gradually increased to higher doses if needed. This minimizes side effects from the medications. Preventive medications are to be taken daily for months to years. When they are stopped, the dose needs to be gradually reduced rather than abruptly stopped. Abruptly stopping preventive medications can lead to headaches.
- In some instances, more than one drug may be needed. Non-medication and behavioral therapies also may be needed.
What is the treatment for menstrual migraine?
There are several aspects to treating menstrual migraines:
- To abort menstrual migraine, take medications after the onset of menstrual migraine. Generally, medications that are effective in aborting non-menstrual migraines are effective at aborting menstrual migraines.
- To prevent menstrual migraine, take medications just before the onset of menstruation and continue for the duration of the expected headache. Taking hormones such as estrogens or estrogen related medications also help to prevent migraine.
- To reduce the frequency and duration of menstrual migraine, take prophylactic medications (such as beta blockers, calcium channel blockers, anticonvulsants, tricyclic antidepressants) that are normally used on a continuous basis to prevent non-menstrual migraines.
NSAIDs such as naproxen sodium (Aleve) or ibuprofen (Advil, Motrin) have been used effectively to abort menstrual migraines. A combination analgesic containing acetaminophen, aspirin, and caffeine (ACC) can also be used to treat menstrual migraines. For women whose menstruation and menstrual migraines occur on a regular and predictable pattern, NSAIDs may be used 24 hours before the expected onset of menstrual migraine and continued for the expected duration of the headache. Since NSAIDs inhibit prostaglandins, they have the added benefit of relieving menstrual cramps as well. For NSAIDs side effects and precautions, please read the "Medication therapies for migraine" section of this article.
Triptans (naratriptan, rizatriptan, sumatriptan, zolmitriptan) have been found to be effective in aborting menstrual migraines, as well as controlling the associated nausea and vomiting. Sumatriptan given 2-3 days before and continued for the duration of the expected headache was found to be effective in reducing the frequency and severity of menstrual migraine. Naratriptan used in the same manner has also been found to be effective in preventing menstrual migraine. However, in those cases where breakthrough headaches occurred, they were just as severe as in patients taking placebo. For side effects and precautions of triptans, please read the "Triptans" section of this article.
Dihydroergotamine (DHE) can be used as a nasal spray or given intramuscularly or intravenously to abort menstrual migraines. Ergotamine (oral, rectal, or intranasal) and DHE (intranasal, intramuscular, or intravenous) can be used around the time of menstruation (several days before and continued for the duration of the expected headache) to prevent menstrual migraines. For ergot side effects and precautions, please read the "Ergots" section in this article.
If these medications are ineffective, doctors may try daily preventive medications such as beta-blockers, anticonvulsants, calcium channel blockers, and tricyclic antidepressants to reduce the frequency and the severity of menstrual migraines. The choice of the preventive medications is based on the experiences and preferences of the doctor, the medication side effects, and the woman's other associated medical conditions.
For women already taking preventive medications and yet still experience headaches, the doses of preventive medications can be increased around the time of the menstruation (some doctors use preventive medications only around the time of the menstruation). Alternatively doctors may try hormone treatment.
Since a drop in estrogen level just prior to menstruation is the trigger for menstrual migraines, estrogen replacement before menstruation has been used in preventing menstrual migraines. For some women with menstrual migraine, Estradiol skin patches (such as TTS 50, TTS 100) applied 2 days before menstrual migraine and continued for 7 days during the expected headache period is effective. However, the dose of estrogen must be closely monitored, as too high of a dose can actually trigger migraine in susceptible individuals.
Some women with difficult to treat menstrual migraines may be helped by using low dose oral contraceptives to reduce the estrogen fluctuations. Other less frequently used medications for menstrual migraines include tamoxifen, bromocriptine, danazol and gonadotropin-releasing hormone (GnRH).
Conclusions
Migraine is often under-diagnosed and under-treated. There is no cure for migraine. Nevertheless, there are numerous interventions that may help restore an improved life for migraine sufferers. These measures should consider the various aspects of the particular patient's condition. Triggering factors, nerve inflammation, blood vessel changes and pain are each addressed aggressively. Individualizing treatment is essential for optimal outcome.
References:
1. Stephen D. Silberstein, MD, FACP. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55:754-762.
2. Roger Cady, MD, David W. Dodick, MD. Diagnosis and Treatment of Migraine. Mayo Clin Proc. 2002;77:255-261.
3. Dowson AJ, Lipscombe S, Sender J, Rees T, Watson D. New Guidelines for the Management of Migraine in Primary Care. Curr Med Res Opin. 2002;18(7):414-439.
4. Patwardhan MB, Samsa GP, Lipton RB, Matchar DB. Changing physician knowledge, attitudes, and beliefs about migraine: evaluation of a new educational intervention. Headache. 2006 May;46(5):732-41.
5. Holroyd KA, Drew JB. Behavioral approaches to the treatment of migraine. Semin Neurol. 2006 Apr;26(2):199-207.
6. Ramadan NM. Migraine headache prophylaxis: current options and advances on the horizon. Curr Neurol Neurosci Rep. 2006 Mar;6(2):95-9.
7. National Guideline Clearinghouse. Treatment of primary headache: acute migraine treatment. Standards of care for headache diagnosis and treatment.
From: Landy S, Smith T. Treatment of primary headache: acute migraine treatment. In: Standards of care for headache diagnosis and treatment. Chicago (IL): National Headache Foundation; 2004. p. 27-39. [11 references].
8. Vincenza Snow, MD. Acute Migraine Treatment Guideline. Annals of Internal Medicine. 2003 Oct 1; 139(7):603-4.
9. National Guideline Clearinghouse. Pharmacologic management of acute attacks of migraine and prevention of migraine headache. From: Snow V, Weiss K, Wall EM, Mottur-Pilson C. Pharmacologic management of acute attacks of migraine and prevention of migraine headache. Ann Intern Med 2002 Nov 19;137(10):840-52. [121 references].
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Medically Reviewed by: Joseph Carcione, D.O., M.B.A., Board Certified Neurology
After 20 years and what seemed like endless drug combinations, my doctor decided to try Imitrex. At first I was skeptical, at this point I had all but given up. To my surprise, it worked! It takes away all traces of the migraine with none of the side effects that I had experienced with other medications. While it is very pricey, I find that it is well worth it just to be able to have my life back. I would recommend that all migraine sufferers discuss Imitrex with their doctor. Published: October 09 ::
I have been "dealing" with Migraines for over 30 years. Originally the doctors tried to medicate me with Fiorinal and Valium which left me unable to function properly so I stopped taking them and took BC Powders, Excedrin, Tylenol, and Advil not at the same time but each helped to dull the pain so that I could go on with daily life. Over the past few years my doctors have prescribed Inderal for daily use in hopes of minimizing the pain or frequency. This did not work but did slow down by ability to think, so I weaned myself off of the Inderal. Zomig helps but causes my joints to hurt and my scalp to be sensitive for about 12 hours. Axert works pretty well. I've recently been prescribed Topamax however I had to discontinue due to excessive headaches and nausea that were a side effect. So, I guess I'll stick with Advil, Tylenol and Axert. Published: September 17 ::
I’ve been getting migraines off and on for about 15 years and as you have probably heard before they were really bad. They would come and go over the course of 2 years. I would get them almost daily 20-15 Advil per day, blew an entire settlement to try and find the cause and 26mg Imitrex per day, that stuff is great, anyway my doctor prescribed me amitriptyline 10mg 1 per night before I go to bed, now remember I was very skeptical because I had done everything for treatment for 10+ years that either didn’t work or was too expensive. That’s my story I haven’t had a migraine for over 4 years. I hope this story can help. Published: August 12 ::
I used to suffer about 30 excruciating migraines a month. I was placed on Inderal and Topamax. I now suffer about 12 to18 per month. When the actual migraine hits, I usually take two Midrin and lie down in a dark room. If that doesn't work, I take one more Midrin and drink a Mountain Dew and continue to lie down. Usually that works. While in bed, I try to think of something soothing and relaxing that takes my mind away from the pain. About 50% of the time this works. I also take Zofran for nausea. Published: July 31 ::
I suffered from Cluster headaches excruciating pain everyday. I had 3 small arteries cauterized which took 20 minutes and that has put an end to my migraines which I suffered with for over 10 years. I am no longer on pain killers, or anti-depressants etc. I now have a wonderful quality of life and feel wonderful. Lots of energy and very motivated. Published: July 30 ::
I have had migraines of differing severity for 15 years. Recently, I was put on Nortriptyline (tricyclic antidepressant) and it is working better than anything previously. I take 20mg every night at bedtime and I take Midrin whenever I get a headache. Also, I lay down if possible with a cold pack across my forehead and eyes. Published: July 24 ::
I've been experiencing migraine headaches for five years. I tried almost every kind of medication. I also underwent bio feedback and used homeopathic medicines. Miraculously, the only thing that worked for me after years of pain and constant suffering was acupuncture. I recommended it to a friend of mine who also suffers from chronic migraines. It also worked with her, although not as much as it did for me. I go for acupuncture at least once a year, and whenever I get an attack now, it is controlled. I only take over-the-counter Motrin now, and I don’t have to rely on the drugs that made me drowsy, moody, and more miserable. Published: October 09 ::
I am a woman from Sweden. I suffer from migraines in relation with my menstruation, normally one day before. Lately, every slight headache turns into a migraine. I buy my best and most economic medicines in Spain: Tonopán and Hemicraneal. The ones I have been given with prescription here in Sweden (Maxalt, Zomig, Imigran) have not been very effective and are extremely expensive. Anyhow, I think I will try acupuncture again. I got the impression that I got migraines less often during one year after a couple of sessions. Published: October 09 ::
Midrin had been the only medication that worked for migraine relief for many years for me. I now see that it seems to have stopped working, which I don’t understand. I absolutely dread the thought of another migraine. Published: August 21 ::
I started getting migraines after a head injury with a history of seizures. I had IV drug therapy last week which lasted a couple days. I have Fiorinal which works when throwing up does not occur. I also take a 600mg ibuprofen with the Fiorinal, since ibuprofen will not work on it's own. I also have eye glasses now which do not help the migraine at all, and take them off. I quit eating many foods, drink a lot of water and try and stay clear of processed foods. I exercise when I am not numb. Try and stay clear of stress and I stopped driving for everyone's safety. Published: August 12 ::
Magnesium is well supported in the scientific literature for prevention and treatment of migraine headaches. It is nature's calcium channel blocker. It works well for me. Published: August 07 ::
When I get a mirgraine, I get a shot of Nubain and within five minutes the pain is gone. Published: August 05 ::
The best thing for me is a combination of acetaminophen, aspirin, a Mountain Dew and an ice pack on the back of my neck or over my eyes. I have tried the combination meds that have caffeine, acetaminophen and aspirin together in them but they just don't work as well as taking the Tylenol and aspirin separately and drinking the caffeine. I have even tried other caffeinated beverages like coffee and tea and they just don't work as well as Mountain dew, not sure why. Usually the headache goes from crippling to bearable in about 20 minutes. Published: July 16 ::
Maxalt is the only thing I've found effective, if I take it early enough. Published: July 02 ::
Taking three 200mg Ibuprofen with a glass of cold Pepsi or Cola and laying down in a quite, dark room. Published: May 30 ::
I have suffered from migraine headaches since I was a child. I have been taking Imitrex for about 10 years, but since I have 4-7 headaches a week that is a lot of medicine. I recently went for Botox to improve my appearance, and after the 2nd visit I noticed that I had very few migraines, so I did some research I found out that Botox works for 75% of migraines sufferers. After the Botox wore off I was back to having migraines almost everyday. It is a very expensive remedy but it is now a must for me. I only wish that health insurance would pay for it. Published: October 15 ::
I have gotten to the point where no treatment is working for my migraines, so I have been suffering tremendously. The migraine I have now, I got on September 2nd, and I cannot get rid of it, no matter what medicine I take. Published: September 17 ::
I have been getting migraines since I was 17, and the only thing that works for me is Fiorinal. I have tried many other pills, but these seem to work the best. Published: July 31 ::
I have had migraine headaches since I was 15 and the only medicine that stops it is Ergos. But I have to say that exercise is the best to prevent migranes. Keep out of stress with yoga or daily exercise. Also, eating healthy food and drinking a lot of water--this is the key too. Published: July 22 ::
Migraine Headache Index
Featured: Migraine Main Article
Migraine is usually periodic attacks of headaches on one or both sides of the head. These may be accompanied by nausea, vomiting, increased sensitivity of the eyes to light (photophobia), increased sensitivity to sound (phonophobia), dizziness, blurred vision, cognitive disturbances, and other symptoms.
I have suffered from chronic daily migraines for the last 10 years. At one point, I was on six daily medications to keep them under control. I have gone through Zomig, Imitrex (pills, nasal inhaler, and shots) Axert, Amerge, and have now settled in with Maxalt (quick dissolving). The best thing I have done for treating my migraines is to have Botox injections. Since my first set of injections, I am down to only one daily medication, and my headache frequency is down an estimated 75%, even when eating "trigger" foods. I am due for another round of Botox next week, and I would love to wean off the remaining beta blocker after this set of injections, and be medicine-free, except for the injections. Published: October 09 ::