Migraine headaches - InDepth

An in-depth report on the causes, diagnosis, treatment, and prevention of migraine.

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Highlights

Migraine Triggers

Migraines can be triggered by many everyday things. Different people respond to different triggers, so it is important to track your migraine patterns by keeping a migraine journal to help you identify and avoid things that set off your migraine attacks. Common migraine triggers include:

• Emotional stress
• Intense physical exertion
• Abrupt weather changes
• Lack of sleep
• Skipping meals
• Hormonal changes with menstrual cycle
• Certain foods and food additives including aged cheese, chocolate, red wine, mono-sodium glutamate (MSG), and many others

Migraine Treatment Approaches

Migraines need a two-pronged approach: prevention and active treatment. Preventive strategies begin with non-drug approaches, including behavioral therapies and lifestyle changes. If headache attacks continue to occur at least once a week, or if your attacks do not respond well to treatment, your doctor may recommend you try preventive medication. Drugs used for migraine prevention include anticonvulsants, beta-blockers, antidepressants, botulinum toxin, and calcitonin gene-related peptide (CGRP) antagonists. There are also medical devices used for preventive treatment of migraine. In some cases, acupuncture may assist with prevention of migraine attacks.

Treatment uses medications that provide quick pain relief when attacks occur. These drugs include pain relievers such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (Tylenol, generic), triptans such as sumatriptan (Imitrex, generic), and ergotamine drugs.

New Drugs and Devices Approved for Migraine Treatment and Prevention

Newer treatments approved or being evaluated include:

• A few monoclonal antibody drugs that work as CGRP receptor antagonists have been approved for the preventive treatment of migraine.
• Two new classes of drugs called gepants (CGRP receptor antagonists) and ditans (serotonin receptor agonists) have been approved for the acute treatment of migraine.
• A transcranial magnetic stimulation (TMS) device has been approved for treatment of acute migraine and as preventive therapy.
• A transcutaneous electrical nerve stimulation (TENS) device to stimulate the trigeminal nerve has been approved for prevention of migraine.

Five Migraine Don'ts

The American Headache Society recommends against these migraine tests and procedures because they are unnecessary, and potentially harmful:

• Don't perform imaging tests on people who have stable headaches that meet the criteria for migraine. People who have been diagnosed with migraine don't need an imaging test unless they have sudden new or worsening symptoms or abnormal findings on their neurological examination.
• Don't perform a computed tomography (CT) scan if a magnetic resonance imaging (MRI) test can be performed. CT scans expose people to radiation, but MRIs do not.
• Don't consider migraine surgery outside of a research trial. Surgical procedures to treat migraine are still considered experimental and are not part of standard clinical practice.
• Don't use opioid medications as first-line treatments for migraine. Narcotic drugs can be addictive and they can make episodic migraines become chronic. Likewise, medications that contain combinations of butalbital and caffeine can also be addictive and lead to worsening headaches.
• Don't overuse over-the-counter (OTC) medications for headache. Using OTC pain relievers more than twice a week can increase the risk for medication overuse headache. This is especially true for brands that contain caffeine.

Introduction

Migraine Headaches

Migraine headaches are the second most common type of primary headache after tension-type headaches. A primary headache is a headache that is not caused by another disease or condition.

Migraine headaches typically have throbbing disabling pain on one side of the head, which sometimes spreads to affect the entire head. In fact, migraine comes from the Greek word hemicrania, meaning "half of the head."

Migraines are classified as occurring either:

• With aura (previously called classic migraine)
• Without aura (previously called common migraine)

Auras are sensory disturbances that occur before a migraine attack. They can cause changes in vision, with or without other neurologic symptoms.

Episodic and Chronic Migraine

Migraines usually occur as isolated episodic attacks, which can happen once a year or several times in a week. In some cases, people eventually experience chronic migraine (previously called transformed migraine).

Chronic migraines typically begin as episodic headaches when people are in their teens or 20s, and then increase in frequency over time. A headache is considered chronic when it occurs on at least 15 days in a month, often on a daily or near-daily basis.

The majority of chronic migraines are caused by overuse of analgesic migraine medications, both prescription pain reliever drugs and over-the-counter medications. Medication overuse headaches are also called rebound headaches. Obesity and caffeine overuse are other factors that may increase the risk of episodic migraine transforming to chronic migraine.

Chronic migraines may resemble tension-type headaches and it is sometimes difficult to differentiate between them. The two types of headaches can coexist. It is not uncommon for people with migraine headaches to also have tension-type headaches.

Other Types of Migraine

Less common type of migraines include:

• Menstrual Migraines. Migraines are often tied to a woman's menstrual cycle, typically in the first days before or at the start of menstruation. Estrogen and progesterone fluctuations may play a role. Compared to migraines that occur at other times of the month, menstrual migraines tend to be more severe, last longer, and not have auras.
• Basilar Migraine. Considered a subtype of migraine with aura, this migraine starts in the basilar artery, which forms at the base of the skull. It occurs mainly in young people. Symptoms may include vertigo (a sensation of dizziness), ringing in the ears, slurred speech, unsteadiness, possibly loss of consciousness, and severe headaches.
• Abdominal Migraine. This migraine tends to occur in children. Periodic migraine attacks are accompanied by abdominal pain, and often nausea and vomiting.
• Ophthalmoplegic Migraine. This very rare headache tends to occur in younger adults. The pain centers around one eye and is usually less intense than in a standard migraine. It may be accompanied by vomiting, double vision, a droopy eyelid, and paralysis of eye muscles. Attacks can last from hours to months. A computed tomography (CT) or magnetic resonance imaging (MRI) scan may be needed to rule out bleeding from an aneurysm (a weakened blood vessel) in the brain.
• Retinal Migraine. Symptoms of retinal migraine are short-term blind spots or total blindness in one eye that lasts less than an hour. A headache may precede or occur with the eye symptoms. Sometimes, retinal migraines develop without headache. Other eye and neurologic disorders must be ruled out.
• Vestibular Migraine. These attacks produce episodic dizziness, which can develop alone or with headache and other typical migraine symptoms. Ringing in the ears (tinnitus) and ear fullness are common.
• Familial Hemiplegic Migraine. This is a very rare inherited genetic migraine disease. It can cause temporary paralysis on one side of the body, vision problems, and vertigo. These symptoms occur about 10 to 90 minutes before the headache.
• Status Migrainosus. This is a severe migraine that lasts for a very prolonged period of time. Migraines this severe often require hospitalization.

Causes

The exact causes of migraine headaches are unknown. There is certainly a strong genetic component to migraines. Several different genes are probably involved, which predispose people to having migraines.

Many brain chemicals (neurotransmitters) and nerve pathway disrupters appear to play a role in causing migraines. They include the neurotransmitter serotonin, the neuropeptide calcitonin gene-related peptide (CGRP), magnesium deficiencies, and abnormalities in the channels within cells that transport electrical ions such as calcium.

Migraine may involve a hyper-reactive nervous system. When triggered by various stimuli, this disorder may set off a chain of neurologic and biochemical events, which subsequently affect the brain's blood vessel (vascular) system.

Risk Factors

Sex

Migraines are two or three times more common in adult women than adult men. During childhood, boys and girls are equally affected. After puberty, migraines occur more in girls. Migraines most often affect women ages 20 to 45.

In women, fluctuations of female hormones such as estrogen and progesterone appear to increase the risk for migraines and their severity. About one half of women with migraines report headaches associated with their menstrual cycle. For some women, migraines also tend to be worse during the first trimester of pregnancy, but improve during the last trimester.

Age

Migraine headaches typically affect people ages 25 to 55. However, migraine also affects about 5% to 10% of all children. Many children with migraine eventually stop having attacks when they reach adulthood or transition to less severe tension-type headaches. Children with a family history of migraine may be more likely to continue having migraines.

Family History

Migraines tend to run in families. Most people with migraine have a family history of the condition.

Medical Conditions Associated with Migraines

People with migraine may have a history of depression, anxiety, stroke, epilepsy, irritable bowel syndrome, or high blood pressure. These conditions do not necessarily increase the risk for migraine, but they are associated with it.

Migraine Triggers

Migraines are often triggered by certain events and conditions. Common migraine triggers include:

• Emotional stress.
• Physical exertion (such as intense exercise, lifting, bowel movements, or sexual activity).
• Abrupt weather changes.
• Bright or flickering lights.
• Odors.
• High altitude.
• Travel motion.
• Lack of sleep.
• Skipping meals.
• Food and food additives. Caffeine is one such trigger. Caffeine withdrawal can also trigger migraines in people who are accustomed to caffeine. Red wine and beer are common triggers. Preservatives and additives (such as nitrates, nitrites, and MSG) may also trigger attacks. A headache diary can help track the foods that trigger migraine.

Symptoms

A migraine attack may involve up to 4 symptom phases: prodrome phase, auras, the attack, and the postdrome phase. These phases may not occur in every person or with every headache.

Prodrome Symptoms

The prodrome phase is a group of vague symptoms that may precede a migraine attack by several hours, or even a day or two. Prodrome symptoms may include:

• Sensitivity to light or sound
• Changes in appetite, including decreased appetite or food cravings
• Thirst
• Fatigue and drowsiness
• Mood changes, including depression, irritability, or restlessness

Aura Symptoms

Auras are sensory disturbances that occur before the migraine attack in 1 in 5 people. Visually, auras are referred to as being positive or negative:

• Positive. Auras include bright or shimmering light or shapes at the edge of the field of vision called scintillating scotoma. They can enlarge and fill the line of vision. Other positive aura experiences are zigzag lines or stars.
• Negative. Auras are dark holes, blind spots, or tunnel vision (inability to see to the side).
• Mixed positive and negative. Auras produce a visual experience that is sometimes described as a fortress with sharp angles around a dark center.

Other neurologic symptoms may occur at the same time as the aura, although they are less common. They may include:

• Speech disturbances
• Tingling, numbness, or weakness in an arm or leg
• Perceptual disturbances such as space or size distortions
• Confusion

Migraine Attack Symptoms

If left untreated, attacks usually last from 4 to 72 hours. A typical migraine attack produces the following symptoms:

• Throbbing pain on one side of the head. Pain also sometimes spreads to affect the entire head.
• Pain is worsened by physical activity.
• Nausea, sometimes with vomiting.
• Visual symptoms.
• Facial tingling or numbness.
• Extreme sensitivity to light and noise.
• Looking pale and feeling cold.

Less common symptoms include tearing and redness in one eye, swelling of the eyelid, and nasal congestion, including runny nose. (Such symptoms are more common in certain other headaches, notably cluster headaches.)

Postdrome Symptoms

After a migraine attack, there is usually a postdrome phase, in which people may feel exhausted and mentally foggy for a while.

Complications

Stroke and Heart Disease

Migraine or severe headache is a risk factor for stroke in both men and women, especially before age 50. Research indicates that migraine may also increase the risk for other types of heart problems.

Migraine with aura appears to carry a higher risk for stroke than migraine without aura, especially for younger women. The increased risk is very low, but it is important that women with migraine avoid other stroke risks such as smoking, high blood pressure, and possibly birth control pills.

Some studies suggest that people who have migraine with aura are more likely than people without migraine to have cardiovascular risk factors (such as high cholesterol and high blood pressure) that increase the risk for stroke.

Emotional Problems and Quality of Life

Migraines have a significant negative impact on quality of life, family relations, and work productivity. Studies indicate that people with migraines have poorer social interactions and emotional health than people with many other chronic medical illnesses, including asthma, diabetes, and arthritis. Many people who have migraines also suffer from anxiety (particularly panic disorders) and depression.

Diagnosis

Anyone, including children, with recurring or persistent headaches should consult a health care provider. There are no blood tests or imaging techniques that can be used to diagnose migraine headaches. A diagnosis will be made on the basis of medical history and physical exam. Tests may be necessary to rule out other diseases or conditions that may be causing the headaches. For chronic headaches, your provider may refer you to a neurologist who specializes in migraine.

Diagnostic Criteria for Migraine Without Aura

A diagnosis of migraine is often made on the basis of repeated attacks (at least 5) that meet the following criteria:

• Headache attacks that last 4 to 72 hours.
• Headache has at least two of the following characteristics: Location on one side of the head; throbbing pain; moderate or severe pain intensity; pain worsened by normal physical activity (such as walking or climbing stairs).
• During the headache, one or both of the following characteristics: Nausea or vomiting; extreme sensitivity to light or sound.
• The headache cannot be attributed to another disorder.

Diagnostic Criteria for Migraine With Aura

A diagnosis of migraine with aura (also called classic migraine) is made on the basis of at least 2 attacks that meet the following two criteria and are not attributable to another disorder:

Headache is preceded by one of the following unilateral and fully reversible aura symptoms:

• Visual
• Sensory
• Speech and/or language
• Motor
• Brainstem
• Retinal

Aura symptoms have at least 3 of the following characteristics:

• Each individual aura symptom lasts between 5 and 60 minutes
• Two or more aura symptoms occur in succession
• At least one aura symptom is unilateral
• aAp least one aura symptom spreads gradually over 5 or more minutes
• At least one aura symptom is positive (scintillations, pins and needles)
• Aura is accompanied or followed by headache within 60 minutes

Headache Diary

Try to recall what seems to bring on the headache and anything that relieves it. Keeping a headache diary is a useful way to identify triggers that bring on headaches, as well as to track the duration and frequency of headache attacks. Some tips include:

• Note all conditions, including any foods eaten or change in sleep, preceding an attack. Often two or more triggers interact to produce a headache. For example, a combination of weather changes and fatigue can make headaches more likely than just one of these events.
• For women, keep a migraine journal for at least 3 menstrual cycles. This can help to confirm a diagnosis of menstrual migraine.
• Track medications. This is important for identifying possible medication-overuse (rebound) headache or chronic (transformed) migraine.
• Attempt to define the intensity of the headache pain using a number system, such as:

1 = Mild, barely noticeable

2 = Noticeable, but does not interfere with work/activities

3 = Distracts from work/activities

4 = Makes work/activities very difficult

5 = Incapacitating

Medical and Personal History

Tell your provider about any other conditions that might be associated with headache, including:

• Chronic or recent illnesses and their treatments
• Injuries, particularly head or back injuries
• Dietary changes
• Current medications or recent withdrawals from any drugs, including over-the-counter or natural (herbal or dietary supplement) remedies
• Use of caffeine, alcohol, or recreational drugs
• Feelings of stress, depression, or anxiety
• Family history of headaches

Physical Examination

The provider will examine the head and neck and will often perform a neurologic examination, which includes a series of simple exercises to test strength, reflexes, coordination, and sensation. The provider may ask questions to test short-term memory and related aspects of mental function.

Differentiating Between Migraine and Other Types of Headaches

Migraines and Tension Headaches

Migraine and tension-type headaches have some similar characteristics, but also some important differences:

• Migraine pain is throbbing, while tension-type headache pain is often a steady and dull ache.
• Migraine pain often affects only one side of the head, while tension-type headache pain typically affects both sides of the head.
• Migraine pain, but not tension-type pain, worsens with head movement.
• Migraine headaches, but not tension-type headaches, may be accompanied by moderate-to-severe nausea and vomiting.
• Migraine headaches, but not tension-type headaches, may be accompanied by sensitivity to both light and sound.
• Migraine headaches may be accompanied by visual disturbances called auras. Tension-type headaches do not have auras.
• Some people have both migraine headaches and tension-type headaches.

Migraines and Sinus Headaches

Many primary headaches, including migraine, are misdiagnosed as sinus headaches. It is also possible for people to have migraines with sinus symptoms such as congestion and facial pressure.

Sinus headaches occur in the front of the face, with pain or pressure around the eyes, across the cheeks, or over the forehead. They are often accompanied by fever, runny nose or congestion, and fatigue. In sinus headaches, the nasal discharge is thick green or yellow. Nasal discharge in migraines is clear and watery.

A real sinus headache is a sign of an acute sinus infection (sinusitis), which responds to treatment with decongestants and may sometimes require antibiotics. If sinus headaches seem to recur, the person is likely experiencing migraines.

Imaging Tests

The provider may order a magnetic resonance imaging (MRI) scan to check for abnormalities that may be causing the headaches. For people who have migraine headaches that are stable, imaging tests are often not necessary unless there are new and serious symptoms. Symptoms that may suggest neurologic problems that warrant an MRI include:

• Changes in vision, particularly if the patient complains of visual loss or double vision
• Muscle weakness
• Fever
• Stiff neck
• Changes in mental status, including disorientation
• A sudden or extremely severe headache
• Worsening headaches or headaches that do not respond to routine treatment
• Recent fall or head injury
• History of cancer

For imaging tests, MRIs are preferred over computed tomography (CT) scans because they do not expose people to radiation.

Symptoms that Could Indicate a Serious Underlying Condition

Headaches indicating a serious underlying problem, such as cerebrovascular disorder or malignant hypertension, are uncommon. A headache without other neurologic symptoms is not a common symptom of a brain tumor. People with chronic headaches may, however, miss a more serious condition by believing it to be one of their usual headaches. You should immediately call your provider if your headache or other accompanying symptoms change.

Be sure to call your provider for any of the following symptoms:

• Sudden, severe headache that persists or increases in intensity over the following hours, sometimes accompanied by nausea, vomiting, or altered mental status (this could be a hemorrhagic stroke).
• Sudden, severe headache, worse than any headache ever experienced (possible indication of hemorrhage or a ruptured aneurysm).
• Chronic or severe headaches that begin after age 50 years.
• Headaches accompanied by other symptoms, such as memory loss, confusion, loss of balance, changes in speech or vision, loss of strength in or numbness or tingling in arms or legs (possibility of stroke or brain tumor).
• Headaches after head injury, especially if drowsiness or nausea are present (possibility of hemorrhage).
• Headaches accompanied by fever, stiff neck, nausea, and vomiting (possibility of meningitis).
• Headaches that increase with coughing or straining, or are worse when laying down (possibility of brain swelling).
• A throbbing pain around or behind the eyes or in the forehead, accompanied by redness in the eye and perceptions of halos or rings around lights (possibility of acute glaucoma).

Management of Migraine

Migraine treatment involves both:

• Treating acute attacks when they occur
• Preventing the frequency and severity of attacks

Treating Migraine Attacks

There are many medications for treating a migraine attack. The main types of drugs are:

• Pain relievers [often nonprescription nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen]
• Triptans
• Ergotamines
• Gepants
• Ditans

Some types of medications, such as opioids and barbiturates, should be avoided because they are potentially addictive or dangerous.

It is best to treat a migraine attack as soon as symptoms first occur. Experts generally recommend:

• Start with nonprescription pain relievers for mild-to-moderate attacks. If migraine pain is severe, a prescription version of an NSAID may be considered.
• A triptan is generally the next drug of choice.
• If the initial triptan is unsuccessful after 3 consecutive attacks, switching to another triptan is considered.
• Ergotamine drugs tend to be less effective than triptans but are helpful for some people.
• If all available triptans are ineffective, third-line medications can be prescribed (gepants or ditans).
• Specific medications for treating symptoms such as nausea may be prescribed.

Try to guard against medication overuse, which can cause a rebound effect. Nearly all pain relief drugs used for migraine can cause rebound headache. You should not take any headache medicine more than 2 days per week. This is especially true for OTC medications that contain caffeine. If you find that you need to use acute migraine treatment frequently, talk to your health care provider about preventive medications.

Preventing Migraine Attacks

Preventive strategies for migraine include both drug treatment and behavioral therapy or lifestyle adjustments.

People should consider using preventive migraine drugs if they have:

• Migraines that are not helped by acute treatment drugs
• Frequent attacks (more than once per week)
• Side effects from acute treatment drugs or contraindications to taking them

The main preventive drug treatments for migraine are:

• Beta-blocker drugs [often propranolol (Inderal, generic) or timolol (Blocadren)]
• Anti-seizure drugs [often divalproex (Depakote, generic), valproate (Depacon, generic) or topiramate (Topamax, generic)]
• Tricyclic antidepressants [often amitriptyline (Elavil, generic)] or the dual inhibitor antidepressants venlafaxine (Effexor, generic) or duloxetine (Cymbalta)
• The triptan frovatriptan (Frova) for menstruation-associated migraine
• CGRP antagonists including erenumab, fremanezumab, and galcanezumab

OnabotulinumtoxinA (Botox) injection is approved for prevention of migraine, but it appears to work best for chronic (not episodic) migraine.

Certain herbal and dietary supplements, such as butterbur (Petasites hybridus) and riboflavin, may be effective for migraine prevention.

A preventive medication strategy needs to be carefully and individually tailored, taking into account a person's medical history and coexisting medical conditions. Migraine drugs can have serious side effects.

Preventive medicine is often started at a low dose, and then gradually increased. It may take 2 to 3 months for a drug to achieve its full effect. Preventive treatment may be needed for 6 to 12 months or longer. Most people take preventive medications on a daily basis, but some people use these drugs intermittently (for example, for preventing menstrual migraine).

Some medications, especially certain oral contraceptives, may increase frequency of migraine in some women. In such cases, changing the type of contraceptive or stopping it results in improved migraine control.

You can also help prevent migraines by identifying and avoiding potential triggers, such as specific foods. Relaxation therapy and stress reduction techniques may also help. (See Lifestyle section in this report.)

Treatment Approaches for Children

Migraine Treatment for Children

Most children with migraines need only mild pain relievers and home remedies (such as ginger tea) to treat their headaches. The American Academy of Neurology's practice guidelines for children and adolescents recommend the following drug treatments:

• For children age 6 and older, ibuprofen (Advil, generic) is recommended. Acetaminophen (Tylenol, generic) may also be effective. Acetaminophen works faster than ibuprofen, but the effects of ibuprofen last longer.
• For adolescents age 12 and older, sumatriptan (Imitrex) nasal spray is recommended.

Migraine Prevention for Children

Non-drug methods, including biofeedback and muscle relaxation techniques, may be helpful. If these methods fail, preventive medications may be used, although evidence is weak on the effectiveness of standard migraine prevention drugs in children.

Withdrawing from Medications

If medication overuse causes rebound migraines to develop, you will need to stop taking the drug. (If caffeine is the trigger, you may only need to reduce coffee or tea intake.) People often have the option of stopping abruptly or gradually:

• Most headache drugs can be stopped abruptly, but talk to your provider first. Certain non-headache medications, such as anti-anxiety drugs, anti-seizure drugs, or beta-blockers, require gradual withdrawal under medical supervision.
• Your provider may recommend you take other pain medicines during the first days. Examples of drugs that may be used include dihydroergotamine, NSAIDs (in mild cases), corticosteroids, or valproate.
• Expect headaches to get worse after you stop taking medication, no matter which method you use. Most people feel better within 2 weeks, although headache symptoms can persist up to 16 weeks (and in rare cases even longer).

Medications and Devices for Treating Migraine Attacks

Many different medications are used to treat migraines. Some migraines respond to non-prescription pain relievers such as ibuprofen, acetaminophen, naproxen, or aspirin. Among prescription drugs, triptans and ergotamine are the only types of medications approved by the U.S. Food and Drug Administration (FDA) for migraine treatment.

Other types of drugs, including opioids and barbiturates, are sometimes prescribed off-label for migraine treatment but they can have dangerous side effects. Opioids and barbiturates are not approved by the FDA for migraine relief.

Pain Relievers

Over-the-counter (OTC) painkillers, also called analgesics, are available without a prescription. They are the first step for treating mild-to-moderate migraines. They include:

• Nonsteroidal anti-inflammatory drugs. NSAIDs include ibuprofen (Advil, Motrin, generic), naproxen (Aleve, generic), and aspirin. Products marketed as Advil Migraine or Motrin Migraine Pain are simply ibuprofen in a liquid-filled capsule.
• Acetaminophen (Tylenol, generic). Excedrin Migraine contains a combination of acetaminophen, aspirin, and caffeine.

There are also prescription-only NSAIDs such as diclofenac (Cataflam, generic).

NSAID Side Effects

High dosages and long-term use of NSAIDs can increase the risk for heart attack, stroke, kidney problems, and stomach bleeding. Aspirin does not increase the risk for heart problems, but it can cause other NSAID-related side effects. Frequent or daily use of NSAIDs may worsen migraines and lead to the development of medication overuse headache. The American Headache Society advises against using OTC medications for headache more than twice a week.

Triptans

Triptans were the first drugs specifically developed for migraine treatment. They help maintain serotonin levels in the brain. Serotonin is one of the major brain chemicals involved in migraines.

Triptans are recommended as first-line drugs for adults with moderate-to-severe migraines when NSAIDs are not effective. Triptans have the following benefits:

• They are effective for treating most migraines, as well as tension-type headaches.
• They do not have the sedative effect of other migraine drugs.
• Withdrawal after overuse appears to be shorter and less severe than with other migraine medications.

Sumatriptan

Sumatriptan (Imitrex, generic) has the longest track record and is the most studied of all triptans. Sumatriptan is effective for most people, but for some people headache recurs within 24 hours after taking the drug.

Sumatriptan is available as a fast-dissolving pill, nasal spray, injection, or skin patch. Injected sumatriptan works the fastest of all the triptans and is the most effective, but it can cause pain at the injection site. The nasal spray form is absorbed more quickly than the oral form and can provide relief within 15 minutes.

The newest form of sumatriptan (Zecuity) is a single-use battery-powered skin patch that is applied to the upper arm or thigh when a migraine attack occurs. Pressing a button activates the patch to deliver the drug during a 4-hour period. The patch is approved to treat both migraine pain and nausea.

Other Triptans

Other triptan drugs include almotriptan (Axert), zolmitriptan (Zomig), naratriptan (Amerge, generic), rizatriptan (Maxalt), frovatriptan (Frova), and eletriptan (Relpax). Treximet combines in one pill both sumatriptan and the anti-inflammatory pain reliever naproxen (Aleve, generic). Frovatriptan is recommended for prevention of menstrual migraine; naratriptan and zolmitriptan may also possibly be effective for menstrual migraine.

Triptan Side Effects

Common side effects of triptans may include:

• Tingling and numbness in the toes
• Sensations of warmth
• Discomfort in the ear, nose, and throat
• Nausea
• Drowsiness
• Dizziness
• Muscle weakness
• Heaviness or pain in the chest (especially with sumatriptan)
• Rapid heart rate

Serious side effects may include:

• Complications of heart and circulation. Triptans narrow (constrict) blood vessels. Because of this effect, spasms in the blood vessels may occur and cause serious side effects, including stroke and heart attack. Such events are rare, but people with an existing history or risk factors for these conditions should generally avoid triptans.
• Serotonin syndrome is a life-threatening condition that occurs from an excess of the brain chemical serotonin. Never combine a triptan drug with a serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) drug. Triptans and antidepressants both increase serotonin levels. Taking several drugs that increase serotonin can cause dangerously high levels. Symptoms include restlessness, hallucinations, rapid heartbeat, tremors, increased body temperature, diarrhea, nausea, and vomiting. Seek immediate medical care if you have these symptoms.

Ergotamine (Ergot)

Drugs containing ergotamine (commonly called ergots) constrict smooth muscles, including those in blood vessels, and are useful for migraine. They were the first anti-migraine drugs available. In general, ergotamine does not work as well as triptans but may still be helpful for some people.

Ergotamine is available by prescription in the following preparations:

• Dihydroergotamine (DHE) is an ergot derivative. It is administered as a nasal spray form (Migranal) or by self-injection.
• Ergotamine is available as tablets taken by mouth, tablets taken under the tongue (sublingual), and rectal suppositories. Some of the tablet forms of ergotamine (Cafergot, Migergot) contain caffeine.

Side Effects

Side effects of ergotamine include nausea, dizziness, tingling sensations, muscle cramps, and chest or abdominal pain.

The following are potentially serious problems:

• Toxicity. Ergotamine is dangerous at high dosage levels.
• Adverse effects on blood vessels. Ergot can cause persistent blood vessel contractions, which may pose a danger for people with heart disease or risk factors for heart attack or stroke.
• Internal scarring (fibrosis). Scarring can occur in the areas around the lungs, heart, or kidneys. It is often reversible if the drug is stopped.

Ergotamine can interact with other medications, such as antifungal drugs and some antibiotics. All ergotamine products approved by the FDA contain a "black box" warning on the prescription label explaining these drug interactions.

Ergotamine should not be used by pregnant women because it can cause miscarriage. People with heart or blood circulation conditions should not use these drugs.

Gepants

Gepants are a newer class of migraine drugs that work by blocking the CGRP receptor. Ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT) have both been recently approved by the FDA for the treatment of acute migraine with or without aura. Patients whose migraines have not responded to first and second-line acute migraine treatment might benefit from treatment with these drugs, however their availability is currently limited. Side effects include nausea, tiredness, and dry mouth. Gepants are not useful as preventive medications.

Ditans

Lasmiditan (Reyvow) is another newly approved drug for the acute treatment of migraine with or without aura. Lasmiditan belongs to a class of drugs called ditans, which work by stimulating a subtype of serotonin receptors. The efficacy of lasmiditan is similar to that of triptans. Like gepants, ditans are considered after other treatments have failed. Lasmiditan side effects include tiredness, sleepiness, and dizziness. People who take lasmiditan should not drive or operate machinery for at least 8 hours.

Opioids

Opioid drugs include morphine, codeine, meperidine (Demerol, generic), hydrocodone (Vicodin, generic), and oxycodone (Oxycontin, generic). Opioids are not approved for migraine treatment and should not be used as first-line therapy. Nevertheless, opioid products are sometimes prescribed to treat severe intractable migraine pain. Opioids are not as effective as other types of migraine drugs, they are highly addictive, and can have other dangerous side effects.

Side effects for all opioids include drowsiness, impaired judgment, nausea, and constipation. There is a high risk for addiction, and these drugs can become ineffective with long-term use for chronic migraines. They may also increase the risk of chronic episodic migraines and heightened sensitivity to pain.

Drugs Used for Nausea and Vomiting

Metoclopramide (Reglan, generic) is used in combination with other drugs to treat the nausea and vomiting that sometimes occur either as a medication side effect or migraine symptom. Metoclopramide and other anti-nausea drugs may help the intestine better absorb migraine medications. The battery-powered sumatriptan skin patch (Zecuity) is approved to treat both migraine nausea and pain.

Neurostimulation Device

Neurostimulation devices are sometimes helpful, especially for patients who cannot tolerate anti-migraine drugs due to their side effects.

A transcranial magnetic stimulation (TMS) device (Cerena) has been approved by the FDA for treatment of pain caused by migraine headache with aura. It is a portable device that is placed on the head during a migraine attack. The device generates a magnetic pulse, which delivers electrical current to the occipital area of the brain (at the back of the head). The current is thought to relieve pain by interrupting the abnormal brain activity associated with migraine attacks. Early studies suggest a benefit but experts call for better quality studies.

Side effects of neurostimulation devices are uncommon and include sleepiness, dizziness, and pain or discomfort at the application site.

Medications and Devices for Preventing Migraine Attacks

The FDA's approved drugs for prevention of migraine are:

• Propranolol (Inderal, generic)
• Timolol (Blocadren, generic)
• Divalproex sodium (Depakote, generic)
• Valproate sodium (Depacon, generic)
• Valproic acid (Depakene, generic)
• Topiramate (Topamax, generic)
• OnabotulinumtoxinA (Botox)
• Erenumab (Aimovig)
• Fremanezumab (Ajovy)
• Galcanezumab (Emgality)

Propranolol and timolol are beta-blocker drugs. Divalproex, valproate, valproic acid, and topiramate are anti-seizure drugs. Erenumab, fremanezumab, and galcanezumab are CGRP antagonists. Many other drugs are also being used or investigated for preventing migraines.

Beta-Blockers

Beta-blockers are commonly prescribed to reduce high blood pressure. Some beta-blockers are also useful in reducing the frequency and severity of migraine attacks.

Propranolol (Inderal, generic) and timolol (Blocadren) are approved specifically for prevention of migraine. Metoprolol (Lopressor, generic) is also recommended. Atenolol (Tenormin, generic), and nadolol (Corgard, generic) are other options for migraine prevention.

Side effects of beta-blockers may include:

• Fatigue and lethargy
• Vivid dreams and nightmares
• Dizziness and light-headedness upon standing
• Reduced exercise capacity
• Coldness in legs, arms, feet, hands
• Gastrointestinal problems

If side effects occur, call your health care provider. Never abruptly stop taking a beta-blocker because this can increase the risk for dangerous heart rhythms, heart attack, or other heart problems. Some research suggests that people with migraines who have had a stroke should avoid beta-blockers.

Anti-Seizure Medications

Anti-seizure drugs, also called anticonvulsant medications, are commonly used for treating epilepsy and bipolar disorder.

Divalproex sodium (Depakote, Depakote ER, generic), valproic acid (Depakene, generic), and valproate sodium (Depacon, generic) are collectively referred to as valproate products. Topiramate (Topamax, generic) is another anti-seizure drug. Valproate products and topiramate are the only anti-seizure drugs that are approved for migraine prevention.

Anti-seizure medication side effects vary by drug but may include:

• Upset stomach
• Tingling sensation in arms and legs
• Difficulty concentrating
• Fatigue
• Weight gain (or with topiramate, weight loss)
• Valproate and divalproex can cause serious side effects, such as pancreas inflammation (pancreatitis) and liver damage
• Birth defects

Pregnant women should never use valproate products to prevent migraine. When taken during pregnancy, these drugs can cause decreased IQ scores in children or can cause life-threatening malformations of the brain and spinal cord. Topiramate can also increase the risk for birth defects, particularly cleft palate. Women who are of childbearing age and considering pregnancy should discuss with their doctors other types of migraine-preventive medication.

All anti-seizure drugs can increase the risks of suicidal thoughts and behavior (suicidality). The highest risk of suicide can occur as soon as 1 week after beginning drug treatment, and can continue for at least 24 weeks. People who take these drugs should be monitored for signs of depression, changes in behavior, or suicidality.

Tricyclics and Other Antidepressants

Amitriptyline (Elavil, generic), a tricyclic antidepressant drug, has been used for many years for migraine prevention. It may work best for people who also have depression or insomnia. Tricyclics can have significant side effects, including disturbances in heart rhythms, and can be fatal when overdosed. Although other tricyclic antidepressants may have fewer side effects than amitriptyline, they do not appear to be as effective for migraine prevention.

Venlafaxine (Effexor, generic) is another antidepressant recommended for migraine prevention. It is a serotonin norepinephrine reuptake inhibitor (SNRI). Serotonin-reuptake inhibitors (SSRIs) such as fluoxetine (Prozac, generic) do not appear to be effective for migraine prevention.

Botox Injections

OnabotulinumtoxinA (Botox) is approved for preventing chronic migraine in adults. Botox is given by multiple injections to the head and neck area about every 12 weeks. These injections may help to dull future headache symptoms. Botox appears to work best for chronic migraines. It has not been shown to work for migraines that occur less frequently than 14 days a month, or for other types of headaches (such as tension headaches). The most common side effects are neck pain and headache.

Monoclonal Antibody CGRP Antagonists

CGRP antagonists are a new class of drugs approved by the FDA in 2018 for the preventive treatment of migraine. These include monoclonal antibodies against a molecule called calcitonin gene-related peptide (CGRP) or against its receptor. CGRP is considered an important factor causing migraine pain by dilating blood vessels and increasing inflammation in the brain.

Monoclonal antibody CGRP antagonists approved to date include erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality). They are used in patients with migraine with or without aura who cannot tolerate or did not respond to treatment with other drugs such as anti-seizure, antidepressant, or beta-blocker therapy. These drugs are administered by a monthly injection and have minimal side effects.

There are some safety concerns with these new drugs, including with pregnant women or children.

Neurostimulation Device

The FDA has approved a neurostimulation device for the prevention of migraine headaches. It is a small, portable, battery-powered device that uses transcutaneous electrical nerve stimulation (TENS) to stimulate the trigeminal nerve.

The device resembles a plastic headband and is placed across the forehead, where it delivers an electrical signal through an electrode placed on the skin. It is used once a day for 20 minutes. In studies, the device helped reduce migraine frequency and use of medication. It did not completely prevent migraines and did not reduce the intensity of migraines that did occur.

Side effects of neurostimulation devices are uncommon and include sleepiness, dizziness, and pain or discomfort at the application site.

Other Treatments for Preventing Migraines

Other types of medications and treatments are being used or investigated for prevention of migraines.

Triptans

Frovatriptan is effective for prevention of menstrual migraines. Naratriptan (Amerge, generic) and zolmitriptan (Zomig) may also be helpful.

NSAIDs

Certain over-the-counter and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful for migraine prevention. They include naproxen (Aleve, generic), ibuprofen (Aleve, Motrin, generic), fenoprofen (Nalfon), and ketoprofen (Nexcede, generic). However, daily use of NSAIDs can cause stomach problems and may also lead to a condition called medication overuse headache.

ACE Inhibitors

Commonly used for treating high blood pressure, angiotensin converting enzyme (ACE) inhibitors such as lisinopril (Prinivil, generic) block the production of the protein angiotensin, which constricts blood vessels and may be involved in migraine.

Angiotensin-Receptor Blockers

Angiotensin-receptor blockers (ARBs) such as candesartan (Atacand) are another type of high blood pressure medication being studied for migraine prevention.

Histamine

Subcutaneous (under the skin) injections of histamine may be helpful for migraine prevention.

Nasal Devices

New types of nasal sprays and powders are being researched. Some of them use capsaicin, the chemical found in cayenne peppers, to help relieve pain.

Herbs and Dietary Supplements

Certain herbs and dietary supplements may be helpful for migraine prevention. See Lifestyle Changes section of this report.

Lifestyle Changes

There are several ways to prevent migraine attacks. You should first try a healthy diet, the right amount of sleep, and non-drug approaches (such as biofeedback) for prevention.

Behavioral Treatments

Behavioral techniques that reduce stress may help some people with migraines. They include:

• Biofeedback therapy
• Relaxation techniques
• Cognitive-behavioral therapy

Studies generally find that these techniques work best when used in combination with medications.

Biofeedback

Many studies have demonstrated that biofeedback is effective for reducing migraine headache frequency. Biofeedback uses special feedback instruments that teach you how to monitor and modify physical responses such as muscle tension.

Relaxation Therapy

Relaxation therapy techniques include relaxation response, progressive muscle relaxation, visualization, and deep breathing. Muscle relaxation techniques are simple and easy to learn, and they can be effective.

Some people find that relaxation techniques combined with applying a cold compress to the forehead provide some pain relief during attacks. Some commercially available products use a pad containing a gel that cools the skin for several hours.

Cognitive Behavioral Therapy

Cognitive-behavioral therapy (CBT) teaches how to recognize and cope with life stressors. It can help people understand how their thoughts and behavior patterns may affect their symptoms, and how to change the way the body responds to anticipated pain. CBT may be used in combination with stress management, relaxation, or biofeedback techniques.

Acupuncture

Acupuncture is a Chinese form of treatment that uses thin needles to stimulate specific points aligned with energy pathways in the body. Studies have shown mixed results on the benefits of acupuncture for preventing migraine. Some migraine patients may benefit from acupuncture.

Lifestyle Changes

Making a few minor changes in your lifestyle can make your migraines more bearable. Improving sleep habits is important for everyone, and especially those with headaches. What you eat also has a huge impact on migraines, so dietary changes can be extremely beneficial, too.

Avoid Food Triggers

Avoiding foods and food additives that trigger migraine is an important preventive measure. Common food triggers include processed lunch meats that contain nitrates, dried fruits that contain sulfites, monosodium glutamate (MSG), aged cheese, alcohol and red wine, chocolate, and caffeine. However, people's responses to triggers differ. Keeping a headache diary that tracks diet and headache onset can help identify individual food triggers.

Eat Regularly

Skipping meals can trigger migraines. It is important to eat on a regular schedule.

Stay Physically Active

Exercise is helpful for relieving stress. An analysis of several studies reported that aerobic exercise in particular might help prevent migraines. It is important to warm up gradually, since sudden, vigorous exercise may trigger or aggravate a migraine attack.

Limit Estrogen-Containing Medications

Medications that contain estrogen, such as oral contraceptives and hormone therapy, may trigger migraines or make them worse. Talk to your health care provider about whether you should stop taking these types of medications, reduce the dosage, or switch to another type of drug.

Herbs and Supplements

Manufacturers of herbal remedies and dietary supplements do not need Food and Drug Administration approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been several reported cases of serious and even lethal side effects from herbal products. Always check with your provider before using any herbal remedies or dietary supplements.

Some studies have shown positive effects for certain complementary therapies, but the evidence is limited. Commonly used herbs and supplements for migraine and headache prevention include butterbur (Petasites hybridus), feverfew (Tanacetum parthenium), riboflavin, magnesium, vitamin D, and melatonin. Effectiveness of these supplements is questionable and potentially serious side effects may occur.

Resources

• National Headache Foundation -- headaches.org
• American Migraine Foundation -- americanmigrainefoundation.org
• American Academy of Neurology -- www.aan.com
• National Institute of Neurological Disorders and Stroke -- www.ninds.nih.gov
• Find clinical trials -- www.clinicaltrials.gov

Related Reports

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Review Date: 7/18/2021  

Reviewed By: Joseph V. Campellone, MD, Department of Neurology, Cooper Medical School at Rowan University, Camden, NJ. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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