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Migraine and Headache Management

Advanced Pain Management Contents Resources For Patients Migraine and Headaches

 

Description

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


Treatment Approaches:

Migraine treatment involves both treating acute attacks when they occur, and developing preventive strategies for reducing the frequency and severity of attacks.


Treating Migraine Attacks

Many effective headache remedies are available for treating a migraine attack. Still, many patients are treated with unapproved drugs, including opioids and barbiturates that can be potentially addictive or dangerous.

The main types of medications for treating a migraine attack are:

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

    It is best to treat a migraine attack as soon as symptoms first occur. Doctors generally recommend starting with nonprescription pain relievers for mild-to-moderate attacks. If migraine pain is severe, a prescription version of an NSAID may be recommended. A triptan is generally the next drug of choice. Ergotamine drugs tend to be less effective than triptans, but are helpful for some patients. Depending on the severity of the attacks, and accompanying symptoms, the doctor may recommend taking a triptan or ergotamine drug in tablet, injection, or suppository form. The doctor may also prescribe specific medications for treating symptoms such as nausea.

    Try to guard against rebound effect. Nearly all drugs used for migraine can cause rebound headache, and patients should not take any the drugs more than 9 days per month. If you find that you need to use acute migraine treatment more frequently, talk to your doctor about preventive medications.


    Preventing Migraine Attacks

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

    Patients 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 (usually propranolol [Inderal] or timolol [Blocadren]
      • Anti-seizure drugs (usually divalproex [Depakote] or topiramate [Topamax]
      • Tricyclic antidepressants {usually amitriptyline [Elavil])

        A preventive medication strategy needs to be carefully tailored to an individual patient, taking into account the patient’s medical history and co-existing medical conditions. These drugs can have serious side effects.

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

        Patients 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 below.)


        Withdrawing from Medications

        If medication overuse causes rebound migraines develop, the patients cannot recover without stopping the drugs. (If caffeine is the culprit, a person may need only to reduce coffee or tea drinking to a reasonable level, not necessarily stop drinking it altogether.) The patient can usually stop abruptly or gradually. The patient should expect the following:

        • Most headache drugs can be stopped abruptly, but the patient should talk to their doctor first. Certain non-headache medications, such as anti-anxiety drugs or beta-blockers, require gradual withdrawal under medical supervision.
        • If the patient chooses to taper off standard headache medications, withdrawal should be completed within three days.
        • The patient may take other pain medicines during the first days. Examples of drugs that may be used include dihydroergotamine (with or without metoclopramide), NSAIDs (in mild cases), corticosteroids, or valproate.
        • The patient must expect their headache to get worse after they stop taking their medications, no matter which method they use. Most people feel better within 2 weeks, although headache symptoms can persist up to 16 weeks (and in rare cases even longer).
        • If the symptoms do not respond to treatment and cause severe nausea and vomiting, the patient may need to be hospitalized.


        Resources

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


        References

        • Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM. Does this patient with headache have a migraine or need neuroimaging? JAMA. 2006 Sep 13;296(10):1274-83.
        • Ebell, MH.Diagnosis of migraine headache. Am Fam Physician. 2006;74(12):2087-8.
        • Goadsby PJ. Recent advances in the diagnosis and management of migraine. BMJ. 2006 Jan 7;332(7532):25-9.
        • Lewis D, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein S, et al. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology. 2004 Dec 28;63(12):2215-24.
        • Lewis DW, Winner P, Hershey AD, Wasiewski WW; Adolescent Migraine Steering Committee. Efficacy of zolmitriptan nasal spray in adolescent migraine. Pediatrics. 2007 Aug;120(2):390-6.
        • Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF; AMPP Advisory Group. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007 Jan 30;68(5):343-9.
        • Monastero R, Camarda C, Pipia C, Camarda R. Prognosis of migraine headaches in adolescents: a 10-year follow-up study. Neurology. 2006 Oct 24;67(8):1353-6.
        • Nestoriuc Y, Martin A. Efficacy of biofeedback for migraine: a meta-analysis. Pain. 2007 Mar;128(1-2):111-27. Epub 2006 Nov 2.
        • Pringsheim T, Davenport WJ, Dodick D. Acute treatment and prevention of menstrually related migraine headache: evidence-based review. Neurology. 2008 Apr 22;70(17):1555-63.
        • Sierpina V, Astin J, Giordano J. Mind-body therapies for headache. Am Fam Physician. 2007 Nov 15;76(10):1518-22.
        • Silberstein S, Tfelt-Hansen P, Dodick DW, Limmroth V, Lipton RB, Pascual J, et al. Guidelines for controlled trials of prophylactic treatment of chronic migraine in adults. Cephalalgia. 2008 May;28(5):484-95. Epub 2008 Feb 20.
        • Wilson, JF. In the clinic. Migraine. Ann Intern Med. 2007;147(9):ITC11-1-ITC11-16.

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