Migraine treatments are probably the most discussed issue among patients with Migraine because of their huge impact on our lives. Discussions of Migraine treatments can be quite confusing, partly because there are so many, partly because they’re used for different purposes. Migraine treatments fall into three categories – preventive, abortive, and rescue.
Preventive Migraine treatments
Preventive Migraine treatments are used to reduce the frequency and severity of Migraine attacks. Most doctors recommend preventive treatment if we average three or more Migraine attacks a month, or if our Migraine attacks are especially debilitating. Some people are naturally reluctant to start taking a daily medication that may need to be taken indefinitely. Here’s where we need to stop and think a bit. Migraine is a genetic neurological disease, not just having bad headaches. Most people aren’t so reluctant to take daily medications for diseases such as diabetes or thyroid disease. Once we get our heads around the fact that Migraine is a disease, resistance to taking daily medications seems to lessen.
There are now seven medications that have been officially approved by the FDA for Migraine prevention:
- propranolol (Inderal), a beta blocker originally developed for heart disease and high blood pressure
- timolol (Blocadren), another beta blocker
- divalproex sodium (Depakote and Depakote ER), a neuronal stabilizing agent, also known as an anti-epileptic agent, originally developed for seizure disorders
- topiramate (Topamax), another neuronal stabilizing agent
- erenumab (Aimovig™), one of three medications on the market that was developed specifically for Migraine prevention. Aimovig™ is a biologic, a CGRP monoclonal antibody, which is self-administered through a subcutaneous injection once per month.
- fremanezumab-vfrm (Ajovy™), one of three preventives on the market that was developed specifically for Migraine prevention. Ajovy™ is a biologic, a CGRP monoclonal antibody, which is self-administered through a subcutaneous injection once per month.
- galcanezumab (Emgality™), one of three preventives on the market that was developed specifically for Migraine prevention. Emgality™ is a biologic, a CGRP monoclonal antibody, which is self-administered through a subcutaneous injection once per month.
In addition to the medications approved for Migraine prevention, the FDA has also approved onabotulinumtoxinA (Botox) for the treatment (prevention) of chronic Migraine.
There are many other medications (more than 100 total) that are being used effectively for Migraine prevention. It’s quite common for medications to be prescribed for conditions other than those for which they were first developed. This is called off-label prescribing. Medications prescribed off-label for Migraine prevention include:
- Antihypertensives (blood pressure medications)
- Alpha-2 Agonists such as clonidine (Catapres)
- ACE Inhibitors such as benazepril (Lotensin) and fosinopril (Monopril)
- Beta Blockers such as metoprolol (Lopressor) and nadolol (Corgard)
- Calcium Channel blockers such verapamil (Calan), diltiazem (Cardizem), and feldopine (Plendil)
- Antihistamines such as cyproheptadine (Periactin)
- Tricyclic antidepressants such as amitriptyline (Elavil)
- SSRI antidepressants such as escitalopram (Lexapro)
- SNRI antidepressants such as venlafaxine (Effexor)
- MAOI antidepressants such as phenelzine (Nardil)
- Cox-2 Enzyme Inhibitors such as celecoxib (Celebrex)
- Muscle relaxants such as carisoprodol (Soma) and tizanidine (Zanaflex)
- Neuronal stabilizing agents (anticonvulsants) such as gabapentin (Neurontin) and zonisamide (Zonegran)
- Leukotriene blockers such as montelukast (Singulair) and zafirlukast (Accolate)
- Medications generally used for attention deficit/hyperactivity disorder such as dextroamphetamine (Adderall) and atomoxetine (Strattera)
- Medications developed for dementia or Alzheimer’s disease such as memantine (Namenda)
- Dietary supplements such as Coenzyme Q10, vitamin B2 and magnesium
Abortive migraine treatments
Abortive Migraine treatments work to stop the Migrainous process itself, thus stopping the associated symptoms as well. Patients may still experience the Migraine postdrome, that phase that some people call a “migraine hang-over.”
Abortive migraine treatments include:
- The triptans:
- sumatriptan (Imitrex)
- rizatriptan (Maxalt)
- zolmitriptan (Zomig)
- naratriptan (Amerge)
- eletriptan (Relpax)
- almotriptan (Axert)
- frovatriptan (Frova)
- combination of sumatriptan and naproxen sodium (Treximet)
- The ergotamines:
- dihydroergotamine nasal spray (Migranal)
- dihydroergotamine subcutaneous injection (D.H.E. 45)
- Isometheptene compounds (Midrin equivalents)
In a few cases, triptans are used short-term for Migraine prevention. Naratriptan (Amerge) and frovatriptan (Frova) have been studied and proven effective for the prevention of menstrually-triggered Migraine when taken twice a day for five to seven days beginning two days before the onset of the menstrual period.
Rescue migraine treatments
Rescue Migraine treatments are those taken if abortives fail or if we can’t take the them for some reason. Several types of medications are used to help get through a migraine by reducing migraine pain and nausea and helping us relax. They don’t have the ability to abort a migraine, but will hopefully mask the pain and some other symptoms for a few hours while the migraine runs its course.
Many doctors have stopped prescribing opioids and barbiturates for Migraine. Although this may be, in part, due to the current “opioid crisis” in the United States, there’s another very good reason. Research has shown that any use of opioids and/or barbiturates can make our Migraine situation worse. Use of those medications increases the risk that episodic Migraine will progress to chronic Migraine. When Migraine is already chronic, use of opioids and/or barbiturates makes it far more difficult to get back to episodic status. Thus, if opioids and/or barbiturates (such as butalbital) are used, they should be used only for rescue, not first-line acute Migraine treatments, and they should be used rarely and sparingly.
Medications used for rescue Migraine treatments include:
- Antiemetic (antinausea) medications such as prochlorperazine (Compazine), promethazine (Phenergan), ondansetron (Zofran)
- Muscle relaxants such as carisoprodol (Soma) and tizanidine (Zanaflex)
- Prescription strength NSAIDs such as indomethacin (Indocin) and ketorolac (Toradol)
- Butalbital compounds: butalbital/aspirin/caffeine (Fiorinal), butalbital/acetaminophen/caffeine (Fioricet), etc. (with or without codeine)
- Acetaminophen with codeine, oxycodone, or hydrocodone such as Vicodin, Percocet, Tylenol #3
- Hydromorphone (Dilaudid), meperidine (Demerol)
Devices for Migraine treatment
In addition to the medications used for prevention, there are now devices being used successfully for both Migraine prevention and to treat Migraine attackss when they occur. Two devices now have FDA approval and are available in the United States with a prescription:
- The Cefaly device is an External Trigeminal Nerve Stimulation device (e-TNS) for migraine treatment. A self-adhesive electrode is placed on the forehead and the Cefaly device is magnetically connected to this electrode. Precise micro-impulses are then sent through the electrode to the upper branch of the trigeminal nerve. The Cefaly is also available in Canada.
- eNeura’s sTMS Mini device is a portable delivery system for single-pulse transcranial magnetic stimulation (sTMS). The first generation of this device was called the Spring sTMS. The sTMS Mini works by interrupting cortical spreading depression to stop a migraine attack in progress. Preventively, it works by preventing cortical spreading depression from starting. The sTMS Mini is also available in the United Kingdom, but is not yet available in Canada.
gammaCore Sapphire Vagus nerve stimulator: The Sapphire nVNS device is a hand-held device about the size of a cell phone that can be carried in a purse or backpack. It is now FDA approved for the acute treatment of both Migraine and Cluster Headache.
Wrapping it up
Which medications or devices are part of our regimen depends upon us and our Migraine attacks. People with infrequent mild to moderate Migraine may do fine with abortive medications only. There are also some in that situation who can even manage with a mild pain reliever or over the counter products. For those whose Migraine attacks are frequent, the most effective regimen will include preventive treatment to reduce the frequency and severity of Migraine, abortives to stop Migraine attacks as they occur, and rescue medications to help avoid trips to the emergency room if abortives fail. Some people, particularly those with a history of cardiovascular disease, may not be able to use abortives and will need to limit their regimens to preventive and rescue medications, or perhaps one of the devices discussed above.