Migraines and Their Treatment

Migraines are a type of headache generally associated with light and sound sensitivity. Migraines can be moderate to severe and usually happen on just one side of the head. They can last from a few hours to a few days and are usually described as throbbing. They can happen randomly without warning, or they can be triggered by specific things such as foods, activities, or smells.

Stages of a migraine

Migraines generally have 4 stages. Not everyone who suffers from migraines will experience each of these stages.

• Prodrome: Up to 24 hours before the onset of a migraine, some people experience mood changes, swelling, increased urination, or food cravings.
• Aura: Shortly (minutes to hours) before the headache, some people experience unusual sensations, flashing lights, or weakness.
• Headache: The headache phase generally starts gradually and builds in intensity. There are forms of migraine that occur without pain such as ocular migraines which just cause vision changes.
• Postdrome: After a migraine, many people are confused or exhausted. These symptoms can last up to 24 hours after the headache resolves.

Symptoms of a migraine

Migraines are defined as having at least two of the following characteristics:

• Unilateral: occur on one side of the head
• Intensity: Moderate or severe
• Nature: Throbbing or pulsing
• Activity: Worsening symptoms with regular activity
• GI: Nausea, vomiting
• Sensitivity: Worsening of symptoms with light or sound

Before the onset of migraine symptoms, you may experience an aura. This is an unusual sensation that may include seeing unusual visual changes such as bright spots or flashes of light, loss of vision, pins and needles sensations, weakness or numbness, or trouble speaking (slurring speech or trouble with finding words). Sometimes these symptoms can mimic a stroke or other conditions. If you’re experiencing new or unusual symptoms, you should seek medical care immediately to ensure that something more serious isn’t going on.

What causes migraines?

Healthcare providers don’t fully understand what causes migraines, but they are believed to be related to a neurotransmitter in the brain called serotonin and its effects on blood vessels in the brain. Migraines may have a link to the menstrual cycle in women.

Migraine can be triggered by several different things. Every person is different, so what triggers your migraines may not trigger a migraine in someone else. It’s also possible that the same trigger may not always cause a migraine.

• Stress
• Hormone fluctuations such as the menstrual cycle
• Hunger/fasting
• Weather change
• Sleeping problems
• Strong odors
• Neck pain
• Light
• Alcohol
• Smoke
• Oversleeping
• Heat
• Food
• Exercise
• Sexual activity

Who gets migraines?

Migraines can happen at any age even in children. They are more common in adults and more common in women. A family history of migraines does make you more likely to develop migraines though many people who have migraines don’t have a family history. Having other medical conditions such as depression, anxiety, bipolar disorder, seizure disorders, and sleeping problems can also make you more likely to develop migraines.

How are migraines diagnosed?

There are different types and causes of headaches. Headaches can be caused by muscle tightness, allergies, trauma, bleeding, and many other things. The first step in the diagnosis of migraines is to do a thorough history and physical exam. Your healthcare provider will ask about your headache symptoms, their frequency, how they respond to medications, any other medical conditions, and any other symptoms you may be experiencing. They will also perform a physical exam to evaluate for other signs that could be worrisome. Tenderness of the scalp, abnormal neurological exam, impaired mental status, or fever may all indicate a more serious problem that needs additional workup such as labs or imaging.

Most patients who have migraines do not require imaging or other studies such as labs to make the diagnosis, though MRI may sometimes show findings consistent with migraine (white matter hyperintensities). MRI is typically only ordered if there is a concern for other potential diagnoses or if there is a significant change in symptoms. Laboratory studies are usually only done if there is concern for other diagnoses such as infection or inflammatory conditions.

How are migraines treated?

If you’ve been diagnosed with migraines, there are many treatment options available. Some people can control their occasional symptoms with over-the-counter medications such as ibuprofen or acetaminophen. In other cases, you may need a prescription medication. Prescription medications can be used for immediate relief of migraine symptoms or prevention of migraines in people with frequent migraines.

Medications for acute symptoms (rescue/breakthrough medications)

The first line for treatment of acute migraines is nonsteroidal anti-inflammatory medications such as ibuprofen or acetaminophen, especially in the case of mild migraines. The decision about what medication to use may vary depending on your health conditions and risk profile.

Triptans are another commonly used class of medication in the acute treatment of migraines. Triptans are the first-line treatment for moderate to severe treatment. These medications work on the 5-hydroxytryptamine receptors in the brain. There are seven medications in this class, and just because one didn’t work doesn’t mean that you won’t respond to a different one. These medications may be combined with nonsteroidal anti-inflammatory medications.

Other medications used for migraines include dihydroergotamine which constricts the blood vessels. This medication should not be used if it causes leg cramps or tingling and is not safe in pregnancy. The intranasal preparation of DHE, Trudhesa, was approved in 2021 for the treatment of acute migraine with or without aura. Opioid pain medications may be effective in helping migraines but have a high abuse potential and can cause decreased response to therapy in the future. As a result, opioids are generally not recommended for routine use. Medications may be used to treat migraines as well.

Nurtec (rimegepant), Ubrelvy (ubrogepant), Qulipta (atogepant), and Zavzpret (zevagepant) are all medications that are in a new class of migraines called Gepants. These medications work on a part of the brain called the calcitonin gene-related peptide (CGRP) receptor. Nurtec is administered orally once daily. It is approved for both acute and chronic treatment of migraines. It is available as an oral dissolvable tablet which can be helpful in patients who have vomiting associated with their migraines.

Ubrelvy is indicated for immediate treatment of migraines with or without aura. It is only approved for adults. Qulipta is available as a tablet. The common side effects are constipation, nausea, sleepiness, tiredness, and weakness. Decreased appetite and weight loss are also seen at times. Zavzepret is available as a nasal spray for the treatment of acute migraine with or without aura. It is currently being evaluated for oral administration as well. Side effects of this medication include nausea, nasal discomfort, vomiting, and abnormal taste in the mouth.

Medications for migraine prevention

If you have four or more headaches with eight or more headache days a month, or if your symptoms are debilitating, you may need preventative therapy.

First-line treatments for preventative medications include some blood pressure medications, anti-seizure medications, or antidepressant medications. Some of these medications have better evidence than others. Divalproex, topiramate, propranolol, metoprolol, and timolol all have good evidence supporting their use for preventative migraines. Amitriptyline and venlafaxine are antidepressants that are also frequently used for migraine prophylaxis.

Several newer medications can be used for migraine prophylaxis.

Monoclonal antibodies are now being used in the preventative treatment of migraines. Vyepti, eptinezumab, is an infusion that also targets the CGRP receptors similar to the Gepants. It is one of four medications recently approved in this class. The others include fremanezaumab and galcanezumab, which also target the CGRP receptors, as well as erenumab, which specifically targets CGRP directly.

Two of the Gepant medications can be used as preventative medication as well as preventative treatments. Nurtec (Rimegepant) and Quilepta (atogepant) are both approved for the treatment of preventative migraine in addition to acute migraines.

The choice of which medications to use for preventative migraine treatment will depend on your other medical conditions. If you have a seizure disorder, divalproex or topiramate may be good choices. If you suffer from anxiety or depression, then amitriptyline or venlafaxine may be what your healthcare provider chooses to start. If you have high blood pressure, palpitations, or heart disease, then a beta-blocker may be the best choice. Your healthcare provider will take a thorough history and physical to help determine which medications may be best for you.

Migraines can be extremely disabling and have a significant impact on your life. Monitoring your symptoms and communicating with your healthcare provider is the best thing you can do to take charge of your health. If you have known migraine triggers, then avoiding those triggers when possible is also crucial.

If your healthcare provider has recommended medication for migraines or any other condition, consider using WellRx to help find the best prices in your area. Some people save a little. Some people save a lot.

Dr. Foglesong Stabile is a board-certified Family Physician who enjoys full scope Family Medicine, including obstetrics, women’s health, and endoscopy, as well as caring for children and adults of all ages. She also teaches the family medicine clerkship for Pacific Northwest University of Health Sciences.

References:

https://www.ninds.nih.gov/health-information/disorders/migraine

https://familydoctor.org/condition/migraine/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088284/

https://www.aafp.org/pubs/afp/issues/2021/0900/p316.pdf

https://www.mayoclinic.org/diseases-conditions/migraine-headache/symptoms-causes/syc-20360201

https://www.aafp.org/pubs/afp/issues/2022/0900/acute-headache-adults.html#:~:text=The%20three%2Ditem%20ID%20Migraine,likelihood%20of%20a%20migraine%20diagnosis

https://www.aafp.org/pubs/afp/issues/2018/0215/p243.html

https://www.aafp.org/pubs/afp/issues/2019/0101/p17.html