A migraine is a severe type of headache that is accompanied by several other symptoms. Migraine headache pain is usually sharp and intense. It may be throbbing or steady and is often unilateral (on one side). Besides pain, migraine symptoms may include nausea and vomiting, stuffy or runny nose, chills or hot flashes, confusion, muscle weakness, neck or jaw pain and stiffness, dizziness, or sensitivity to light, sound, touch, smells, or motion. Some people with migraines experience an “aura,” which includes one or more sensory symptoms such as visual disturbances, hearing or smelling things that aren’t there, speech problems, or paraesthesia (numbness, prickling, or tingling, usually on the face or hands), usually before, but sometimes during, the headache. However, most people with migraines experience migraines without aura. Sometimes, people with migraines experience a “prodrome” of symptoms including mood swings, diarrhoea or constipation, tiredness, neck stiffness, and/or food cravings 24-48 hours before the headache, which can be warning signs that a migraine is going to happen. However, these are not considered an “aura,” because they are not sensory disturbances.
There are many treatment options for migraines. Several non-medication treatments can be effective in decreasing the frequency and severity of migraines. These include a regular sleeping and eating schedule, exercising regularly, drinking plenty of water, managing stress, and avoiding triggers (food, medications, or activities that tend to bring on a migraine), when possible. Examples of common migraine triggers include stress, bright and/or flashing lights, menstruation (having a period), not enough or too much sleep, hunger, alcohol, loud noises, weather changes, strong smells, caffeine (too much caffeine or caffeine withdrawal), food additives/preservatives such as nitrates and MSG, aged cheeses (ex.-sharp cheddar, asiago, parmesan, Swiss, gruyere), artificial sweeteners, citrus fruits, chocolate, and medications such as cimetidine, nifedipine, hydralazine, hormones, nitro-glycerine). When you feel a migraine coming on, it can help you to go into a dark quiet room, take a nap, and/or use cold compresses on the painful area. When these remedies do not adequately control migraines, or you experience migraines more than just occasionally, medications can help stop migraine symptoms, and prevent migraines from happening.
Pain Relievers, or “analgesics,” are used to treat migraine pain. There are several types of pain relievers. They work by blocking pain signals to the brain. Acetaminophen is available over the counter (OTC) and is used for the treatment of mild pain. NSAIDs (non-steroidal anti-inflammatory drugs) help treat mild to moderate pain and provide the added benefit of treating inflammation that may be present in the blood vessels and nerves during migraines. Examples of NSAIDs include ibuprofen, naproxen, meloxicam, diclofenac, ketorolac, and aspirin. Ketorolac is available as an injectable/IV medication to treat moderate to severe migraine pain. Opioid pain medications may be useful to help treat severe migraine pain that isn’t relieved by less potent pain relievers. These can be addictive and should only be used as a last resort. Examples of opioids include hydrocodone, morphine, codeine, tramadol, meperidine, hydromorphone, and oxycodone.
Triptans are the first-line recommended migraine treatment. They work on receptors in the blood vessels in the head that are usually enlarged/inflamed during migraine headaches to make them constrict (get smaller) to relieve migraine pain. They also help block pain signals in the brain. These are available as oral tablets, nasal sprays, and injections/shots for migraine treatment. Examples include sumatriptan, rizatriptan, eletriptan, zolmitriptan, and naratriptan.
Ergot Alkaloids work similarly to triptans to treat migraines. However, they are an older drug class with more severe side effects. They are recommended as an option to treat migraines when they are very frequent or last longer than 24 hours. Their pain-relieving effects usually last longer than triptans. Ergot alkaloids are available as tablets, nasal sprays, injections, and suppositories. Examples are ergotamine and dihydroergotamine.
CGRP Antagonists block receptors for calcitonin gene-related peptide (CGRP), which is a chemical that causes pain and inflammation in migraines. It can also make the headaches stronger and last longer. Research has found that CGRP levels are elevated in people who have migraines. These are available as pills and a nasal spray. Examples are atogepant, rimegepant, and zamegepant. These new medications may not be readily available in South Africa at this time but are expected to be available soon.
Antiemetics are used to treat nausea and vomiting associated with migraines. They do not affect migraine pain. There are several classes of antiemetics. They generally work by inactivating receptors in the stomach or the brain that trigger vomiting, or by helping move food and drink downward through the digestive tract. Examples of antiemetics used in migraine symptom treatment include ondansetron, promethazine, prochlorperazine, metoclopramide, dimenhydrinate, and meclizine.
Combination Therapies can sometimes be more effective for migraine treatment than a single medication alone. OTC medications containing a combination of aspirin, acetaminophen, caffeine, and/or ibuprofen are marketed for the treatment of migraines. Caffeine is believed to help the body absorb other medications and make pain relievers more effective. The combination of triptans and an NSAID has been found to be more effective at treating migraine than either type of medication by itself. There are several migraine medications available that contain a combination of ergot alkaloid, caffeine, aspirin, acetaminophen, and/or an antihistamine.
Corticosteroids, which decrease inflammation, are sometimes used to help treat a type of severe, prolonged migraine called “status migrainosis” or to help prevent recurrent migraines. Prednisone and dexamethasone are two corticosteroids commonly used for this purpose.
Non-steroidal anti-inflammatory drugs (NSAIDs) can be used for the prevention of migraines that occur predictably during a menstrual period. Taking these medications daily the week before and during the menstrual period can significantly decrease the risk of frequent migraines during your period. However, these medications are not recommended for daily use to prevent other types of migraines, because of the risk of severe side effects. Example medications are ibuprofen, naproxen, and diclofenac.
Calcium Channel Blockers (CCBs) stop the flow of calcium ions into the nerves and blood vessels involved in migraine symptoms. These medications are believed to be more effective for migraine with aura than migraine without aura. Examples of CCBs used for migraine prevention are verapamil, nifedipine, diltiazem, and nimodipine.
Beta Blockers are a first-line choice for migraine prevention. They are usually used for heart/blood pressure conditions and are believed to help stop pain signals and affect the blood vessels, nervous system, and brain chemicals involved in migraine. Medications used for migraine prevention include propranolol, metoprolol, timolol, atenolol, and nadolol.
Anti-Seizure Medications are believed to help prevent migraines because seizures and migraines are believed to have some of the same physical features. They are also usually a preferred option for migraine prevention. These medications are not usually recommended in women of childbearing age because of the risk of pregnancy complications. Examples of these medications include topiramate, divalproex, valproic acid, and carbamazepine.
Antidepressants target some of the same brain chemicals that are involved in migraine pain. These are often used if a patient also has depression symptoms along with migraines. Examples of antidepressants used are amitriptyline, nortriptyline, venlafaxine, and duloxetine.
Botulinum Toxin (aka “Botox”) is a nerve toxin injected in small quantities, usually to relax facial muscles and decrease the appearance of wrinkles. It has been found to help prevent migraines when injected about every three months. Botox is believed to prevent migraines by blocking neurotransmitters, or nerve chemicals, that cause migraine pain. It is important that this treatment be performed by a doctor who specializes in Botox injection specifically for migraines, not cosmetic procedures.
CGRP Monoclonal Antibodies are long-acting injections with the same mechanism of action as the CGRP antagonists used for migraine treatment. These are given every 1-3 months to prevent migraines.
There are several side effects possible with medications taken for migraine treatment and prevention. The most common and expected ones are listed below:
Medication Overuse Headaches can occur when you take migraine/headache medications too often. These headaches may be more intense and more frequent than your regular migraines. It is important that you take medications exactly as prescribed and use the lowest possible dose to gain relief to prevent these overuse/ “rebound” headaches.
Bleeding Risk is increased with some migraine medications, especially NSAIDs when taken regularly. You should seek medical attention right away if you have unusual bruising or bleeding, or blood in your vomit or faeces. It may look bright red or can cause black, tarry stools, or a coffee ground appearance in vomit.
Drug Interactions can be significant and require changes in therapy with some of these medications. It is important that your doctor and/or pharmacist are aware of every medication you are taking, including over-the-counter medications and supplements so that they can monitor for drug interactions.
Seizure risk, though rare, may be increased with some of these medications. Most often, this is related to stopping a medication suddenly. It is important that migraine prevention medications are stopped only under the direction and supervision of a healthcare provider.
Heart Arrhythmias are a rare, but possible side effect of some migraine medications. Many of these medications should be avoided in people with a history of heart problems or uncontrolled blood pressure.
Organ Failure is possible when taking these medications long-term, particularly liver and kidney damage. These can usually be detected with routine bloodwork. If you experience decreased urination, yellowing of the skin/whites of eyes, or severe abdominal pain, seek medical attention right away.
Though migraines can be very painful and disruptive, there are many treatment options available. It is important that you take medications exactly as prescribed or directed by your healthcare provider. While migraine treatment medications are intended to relieve symptoms quickly, usually within an hour, it is important to remember that preventative medications may take several weeks to become effective, and they must be taken daily, not at the onset of a migraine. You should never stop taking medication unless under the direction of your provider. Several of these medications should not be taken during pregnancy, so contact your healthcare provider right away if you plan to become pregnant or find out you are pregnant while taking medication for migraines. It is important that you receive a diagnosis of migraine with aura before continuing to self-treat with over-the-counter medications and home remedies. Several symptoms of migraine may be associated with more serious health conditions. If you have a new onset of symptoms, especially problems with speech, walking, numbness/tingling, or what you would describe as “the worst headache of your life,” you should seek medical attention immediately. In severe cases of migraine that do not respond well to medication treatment, there are surgery options or devices such as nerve stimulators that may help. You should talk to your doctor about available treatment options.