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What treatments are prescribed for migraines?

Dr. Charisse Litchman

Medically reviewed by Dr. Charisse Litchman, MD, FAHS on August 18, 2020

There are a number of different migraine treatments, each based on one of the theories researchers have for why you develop migraines. There are five main theories of what causes migraines: changes in the electrical firing from your neurons (your brain cells) 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; and release of a chemical called CGRP (calcitonin gene-related peptide).

The first step your provider will take in choosing the right treatment for you is to learn from you what triggers your headaches, how often you get a headache, what your headache feels like, how bad the pain is, and whether you have any other medical problems.  

Of the medications described below, all of them help many patients, not all of them work equally well for all patients. There is usually no clear explanation as to why some medications work better for a patient than another. 

Abortive Medications 

These are medications you take when you experience a headache. All of these medications will work better if taken soon after the headache starts. There has been a great deal of progress in the development of new medications to “abort” or take your headaches away.   

Over-the-counter painkillers and prescription anti-inflammatories: For mild to moderate headaches, some people respond to over-the-counter Tylenol or Advil, or prescription anti-inflammatory medications.

Prescription triptans:  For moderate to severe headaches, many patients see success with medications called “triptans.”  The triptan drugs were the first medications ever designed specifically to treat migraines. They work by stimulating serotonin (a chemical in the brain), reducing inflammation and narrowing 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 heart disease or other high-risk conditions like uncontrolled hypertension. 

Prescription ditans: These newer medications also work by increasing the effects of serotonin. Because these drugs dilate the vessels, they are safer for many patients than triptans. The ditans can cause dizziness and are sedating. You must not drive for hours after they are taken.

CGRP blockers: Called “gepants,” these medications block the chemical CGRP. When released, CGRP causes the release of pain chemicals in the brain; so by blocking CGRP, the migraine ends quickly in most patients. These medications are also safe for most patients.

Preventive Medications 

These are medications taken daily to prevent headaches or reduce their frequency. When headaches occur more often than 4 days per month or do not respond well to abortive medications, patients may be prescribed preventive medications which will reduce the frequency of or block the onset of headaches. Some headaches may still occur, and it is safe to use abortive medications to stop them.  

Generally, you should consider a preventive medication if you experience 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 of your arm or leg. 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 having them will affect which treatments might work best for you.

Vitamins and supplements: First line preventives are often over-the-counter vitamins and supplements. For example, magnesium, melatonin, Co-Q10, and vitamin B2 can decrease headache frequency.

Antiseizure medications (like Topamax): These can prevent migraines by changing the electrical changes that occur at the onset of a migraine.

Antidepressant medications (like escitalopram or nortriptyline): These can prevent headaches by stabilizing serotonin levels, even in people who are not suffering from anxiety or depression. 

Blood pressure medications (like metoprolol): These may prevent headaches by stabilizing the size of blood vessels around the brain. They can be used in many people who have normal blood pressure.

Botox injections (injections given by providers every three months) that block the release of the chemical CGRP and Monoclonal antibodies (monthly self-injections) that bind with the chemical CGRP (like Emgality) or the receptor for CGRP (like Aimovig) are very effective in blocking headaches. Again, not all of these medications work equally well or are as well-tolerated in all people.

Birth control: 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. Or women may be prescribed non-hormonal medications to be used only when their periods start or they may be given hormones to block their periods entirely.

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