Migraines are extremely common, especially among women — approximately 1 in 6 experience migraines at some point in their lives. But the specific causes and characteristics of migraines vary greatly from person to person. In fact, even though this is frequently an inherited disorder, meaning that when someone in your family experiences migraines it’s more likely that you too will suffer from them, each family member will experience migraines differently. One family member may have only one headache a few times a year while another may have daily headaches. Every family member may respond differently to treatment as well.
Step One: Evaluation
Because migraines are such an individual experience, it may require working with a provider for a while to find the treatment that works best for you. The first step your provider will take is to ask what triggers your headaches, how often you get a headache, what your headaches feel like, how bad the pain is, and whether you have any other medical issues. Your provider will ask you about food triggers and may suggest you remove certain foods from your diet. For example, if you develop a headache every time you drink red wine or every time you eat Chinese food, then you will be asked to avoid these foods. If you are drinking five cups of coffee per day or eating peanut butter five days a week, then you will be asked to reduce the amount and frequency of these foods in your diet.
If adjusting your diet does not solve the problem, then your provider will decide whether you only need abortive medications (those taken to stop or lessen a headache when you experience one) or preventive medications (medications taken daily to prevent the headaches from coming at all or to reduce their frequency). Generally, a preventive medication will be considered if you have more than four days of headaches per month, if your headaches are very severe and difficult to stop, or if you have neurologic symptoms with your headaches, like not being able to speak or weakness in your limbs. Your provider will need to know your entire medical history, including heart, kidney or liver problems. You will also need to discuss any anxiety or depression you are feeling. While anxiety and depression do not cause migraines, they can make it harder to treat migraines and experiencing them will affect which treatments might work best for you.
Medication to Stop Migraines
There are multiple theories about why people experience migraines, and migraine treatments have been developed to address each of the possible physiological causes. These are the five main theories of the cause of migraines:
- Changes in the electrical firing from your neurons, called Cortical Spreading Depression
- Changes in your serotonin levels
- Inflammation around your nerve cells
- Changes in the size of the vessels around your brain (called the “vascular theory”)
- Release of a chemical called CGRP (calcitonin gene-related peptide)
There has been a great deal of progress in the development of new medications to “abort” or take your headaches away. For mild to moderate headaches, some people respond to over-the-counter Tylenol or Advil or prescription anti-inflammatory medications. When anti-inflammatories don’t work well, many patients with moderate to severe headaches experience relief with a category of prescription medication called “triptans.” The triptan drugs were the first medications ever designed specifically to treat migraines.They work by stimulating the brain chemical serotonin, which reduces inflammation and narrows the blood vessels, ultimately stopping the migraine. These medications are not for everyone because the narrowing of the vessels may be dangerous for patients with conditions like heart disease or diabetes.
For patients who can’t take triptans, there is a newer type of migraine medication called ditans, which also work by increasing serotonin but dilate the blood vessels instead of constricting them, making them safer than triptans for many patients. There is also a new group of drugs called gepants (like Ubrelvy and Nurtec), which block the chemical CGRP. When released by the brain, CGRP causes inflammation and pain, and, by blocking CGRP, the migraine ends quickly in most patients.
While each of these options helps many patients, not all work equally well for all. There is usually no clear explanation as to why some medications work better for a patient than another. This is why patients may need to try a range of treatments before finding the best solution for their headaches.
Strategies to Prevent Migraines
When headaches occur more than 4 days each month or do not respond well to the abortive medications described above, medical providers may prescribe preventive medications designed to reduce the number of headaches or prevent them from occurring at all. Often a provider will recommend patients start by taking over-the-counter vitamins and supplements — magnesium, melatonin, coenzyme Q10 and vitamin B2 can decrease headache frequency.
If OTC options don’t help, there are a few different prescription options. Some anti-seizure medications (like Topamax) can prevent migraines by changing the electrical changes that occur at the onset of a migraine. Certain antidepressants (like nortriptyline or lexapro) can prevent headaches by stabilizing serotonin levels, even in people who are not suffering from anxiety or depression. Blood pressure medications (like propranolol or verapamil) may prevent headaches by stabilizing the size of blood vessels around the brains.
There are also injectable medications, called monoclonal antibodies, that you can administer at home once a month. These either bind with the chemical CGRP (like the medication Emgality) or the receptor for CGRP (like Aimovig) and are very effective in blocking headaches. Botox injections, originally developed for cosmetic purposes, can prevent headaches in many people, though they must be administered by a medical provider.
Finally, in women whose migraines are associated with their periods, starting or changing how you take birth control may be an effective way to reduce how often you get migraines. Again, not all of these medications work equally well or are as well tolerated in all people. Usually people who take preventive medications are still prescribed abortive medications as well, to block headaches that still occur.
Many people find that changes in lifestyle make a great difference in how they experience migraines. A regular exercise routine, not sleeping too much or too little, not skipping meals, stress-reducing activities and support groups are some of the things that can help migraine sufferers.
When you see your provider or request migraine treatment, you will need to provide information about how often you experience headaches, whether you have nausea and/or light sensitivity with your headaches, whether you experience aura, and what you have identified as triggers for your headaches. They may ask you to track your headaches — how often they occur, how severe they are, and (if you menstruate) whether they occur around your period — so you and your provider can understand patterns and evaluate how well your treatment is working.
While migraines are a serious medical condition, the good news is that there are more treatment options for people with migraines than ever before, and our understanding of this condition continues to grow. If migraines are having a negative impact on your life, I encourage you to seek treatment.
About the Author
Charisse Litchman MD, FAHS is a neurologist, headache specialist, and medical advisor to Nurx. She received her undergraduate degree at Wesleyan University and her medical degree at Yale School of Medicine. After completing her internship at Yale New Haven Hospital, she completed her neurology residency at Cornell-New York Hospital. She began a solo private practice in general neurology and became board certified in headache medicine in 2008. A former Assistant Professor of Clinical Neurology at Yale School of Medicine, Charisse has published articles in headaches and multiple sclerosis and edited the first textbook on a rare soft tissue tumor. She has earned a certificate in Medical Editing and Writing from the University of Chicago. Charisse has three children and lives in Connecticut with her husband Mark and her two dogs.
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