MIGRAINE - Treatment of Migraine

Treatment

There are three different levels of migraine treatment:

• Preventative treatment (stopping attacks from happening)
• Acute treatment (treating an attack as soon as it happens)
• Rescue treatment (dealing with an attack if acute treatment does not work)

Some people are prescribed a number of different drugs before they find a treatment course that suits them. You may find it useful to keep a note of all the drugs you have taken, and how they affected your attacks. This can help you to discuss your treatment history with a doctor long after these details may have been forgotten. A sample record form is available for download.

Preventative treatment

Disabling headaches continue to happen in some people, even after they have made serious attempts to identify and avoid trigger factors, and make lifestyle changes. You should talk to your doctor if you find yourself in this situation, as you may need to take medication to try and stop the attacks from happening.

How often you have a headache is not the only thing a doctor will look at to decide whether to prescribe preventative medication. The decision will be based on the effect the headaches are having on your life.

When headaches are affecting you badly, a doctor can prescribe a number of different preventative medications. Migraine preventatives have usually been developed to treat other conditions. Experience has shown that these drugs also stop migraine attacks from happening.

Therefore, you may be prescribed:

• an anticonvulsant, such as divaloproex sodium (sodium valproate), topiramate or gabapentin
• an antidepressant such as amitriptyline
• an antihistimine, such as cyproheptadine
• a beta-blocker, such as propranolol, metoprolol, timolol, nadolol
• an anti-inflammatory drug, such as pizotefen

Other drugs not listed here may also be used, based on the experience of your doctor. It is important to remember that if a doctor prescribes, for example, an antidepressant for your migraines, you are not necessarily suffering from depression.

A doctor will also talk to you about how long you should take preventative medication.

Migraine-preventative medication is usually used for between 3 and 18 months. This treatment generally leads to a big reduction in the number of headaches the sufferer has. This improvement often carries on when the sufferer stops taking the preventative drug. These drugs can therefore help to break a cycle of migraine in some cases. It is important to record fully any attacks that happen when your are taking preventative medication. You need to watch and record what is happening, to help the doctor decide if the medication is helping to cut down the headaches.

However, some medicines containing combinations of drugs with codeine or caffeine have been strongly suspected of causing the condition known as chronic daily headache. Over-the-counter analgesics often fail because they are taken too late in the migraine attack cycle. The digestive process slows down during a migraine attack. This can reduce drug uptake in the stomach, and the medicine is therefore not effective. Take analgesics in soluble form where possible, as this helps uptake in the stomach. If you can recognize the warning signs that a migraine attack is starting, you should take your medication at this time.

Prescription only medicines

Your doctor can prescribe a number of stronger pain killers, and other medicines that may help to stop a migraine attack. Anti-sickness (anti-nausea or anti-emetic) drugs taken several minutes before an analgesic can help to reduce nausea and speed up the action of the pain killer. Commonly prescribed anti-emetics include domperidone and metoclopramide. Stronger analgesics available include naproxen, diclofenac sodium and tolfenamic acid. Details are on our currently used drugs page.

Many sufferers with severe migraines are treated with one of a class of migraine-specific drugs called triptans. A number of different triptans are now available in the UK. Almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan and zolmitriptan all work in the same way, but the different characteristics of each drug will suit different people. Triptans can be taken as pills, as quick-dissolving tablets, as a nasal spray, or as an injection. On average, patients who take triptans by mouth get relief from the symptoms of migraine in around half an hour. A doctor will be able to talk to you about your specific needs, and the best way to take your medication.

Ergotamine preparations, or sometimes a sedative, can be prescribed when none of above drugs are effective. However, the BNF states 'the value of ergotamine for migraine is limited by difficulties in absorption and by its side effects, particularly nausea, vomiting, abdominal pain, and muscle cramps. It is best avoided'.

As with migraine preventative medication, a doctor prescribing acute treatments will base their decision on an assessment of disability (the effects of the migraine attacks, not necessarily how often they happen). Assessing disability will help a doctor to prescribe the right care to suit you. Ideally, the individual features of your headaches should be matched to a suitable plan for managing them at an early stage. This avoids having to keep going back to see the doctor, who may have to increase the level of treatment if lower levels fail. You should record details of the attacks throughout the treatment programme to help the doctor assess the effect of the medication.

Rescue medication

There may be times when acute medication does not give enough relief from an attack. Your doctor may prescribe different medication to use at these times. ‘Rescue medication’ can be used if your acute treatment does not work. An antinausea (antiemetic) medication (to stop sickness), plus an anti-inflammatory or pain-relieving medication may be prescribed. You should write down when you use rescue medication in your migraine diary. Using rescue medication a lot suggests that your acute treatment needs changing.

Side effects

The action of any drug in the body is complicated. Drugs can act on many places in the body, not just the parts we want them to. This can lead to ‘side effects’ happening, as well as the planned benefits. When prescribing medication, a doctor will talk to you about the possible side effects. These will also be listed on the information sheet that comes with the medication. Write down any changes you feel or notice that you think might be a side effect of the medication. It is important to tell a doctor about these changes. Some side effects go away with time, but a doctor may want to reduce the dose or change the medication.

Dangers of over-using medication - Chronic Daily Headache

There is a condition called 'medication overuse headache', that has been linked with over-using pain killers, such as paracetamol. Some patients with medication overuse have daily headache, when it is called Chronic Daily Headache, meaning headache on at least fifteen days in any one month. The term means only that the headache is frequent; it can have many causes other than medication overuse. Some medicines containing combinations of drugs with codeine or caffeine have also been strongly suspected of causing medication overuse headache. Therefore, rather than managing migraine, regular use of these drugs on more than three days a week can actually make the headaches worse. It is important to avoid over-using medication. You should get medical advice if you are using painkillers on more than three days a week.

Mechanical pain relief

Many sufferers use mechanical techniques to relieve the pain of migraine attacks. Simple techniques that can be tried include:

• Temperature - both hot or cold. Try applying an icepack, or a hot water bottle, to the painful area. Hot or cold showers help some sufferers, or try soaking the hands and feet in hot or cold water.
• Pressure. Try applying pressure to the pulse points on the side of the forehead or neck to relieve the headache.
• Manipulation in the form of massage and reflexology are more complicated techniques, and you may need to find a trained practitioner to get the best results. Osteopathy and chiropractic are also manipulative techniques. To prevent harm, these techniques should only be carried out by a registered practitioner; your doctor may be able to recommend one.

Biofeedback

The biofeedback technique has been used to reduce the number of attacks and the pain of migraine in some sufferers. Biofeedback training teaches people to control certain body functions they do not normally think about controlling. For example, a headache sufferer could learn to raise the temperature of a part of the body, say the hands. Redirecting blood to the hands reduces blood flow in the head, and the headache pain eases. You need professional help to learn the skill of biofeedback. Once a sufferer learns the technique, it can be practised anywhere.

Complementary treatments

Complementary treatments used by migraine sufferers include:

• Acupuncture
• Chiropractic
• Homoeopathy
• Herbalism
• Osteopathy

Reliable, well-designed research studies assessing the effectiveness and safety of these treatments have yet to be performed. However, many GPs are prescribing them as alternatives to mainstream treatments, and some can now be prescribed under the National Health Service.

Botox

Botox is the brand name for botulinum toxin A, a toxin secreted by the bacterium that causes botulism. The potential of Botox as a useful medical intervention was discovered by scientists developing a vaccine to protect against botulism. They found that when injected into muscle, the toxin stays in the injected area (rather than travelling into the bloodstream), and causes the injected muscle to relax.

Following this discovery, Botox has for many years been used in the treatment of disorders involving abnormal muscle contraction. More recently, the toxin has become a household name as a glamour drug, associated with ageing celebrities who rely on the toxin’s paralytic powers to ward off facial wrinkles. Certain Botox users found that wrinkles were not the only unwanted feature soothed by the treatment; the drug also appeared to have a preventative effect on their headaches.

In 2010 Botox was given regulatory approval for treatment as a preventative for chronic migraine.