Migraine Treatments

How Do You Treat Migraine?

If you live with migraine, there can be relief.

There are three different approaches;

Treating the symptoms when they occur (acute intervention)
Using the treatment routinely to reduce the intensity and frequency of migraine attacks (preventive or prophylactic treatments)
Non-medicinal (tracking migraine triggers, lifestyle modifications, devices)

If you are beginning a migraine treatment, you may want to use a Migraine Diary to track its effectiveness.

Acute Treatments

Acute treatments are used when a migraine attack occurs.

Acute treatments approved by the FDA typically demonstrate that they can substantially reduce or eliminate the symptoms of a migraine attack within two hours of taking the medication or using the device. Prescription medications called triptans are the current gold-standard for acute migraine treatment, but they are not safe or effective for every person. If one kind of acute treatment didn’t work well it’s possible that you will have a better result from another, even if it’s in the same class of medication.

People with migraine disease will need at least one acute treatment they can count on to reduce or stop the symptoms of an attack. If you need to use acute medications more than 2 headache days per week, then your provider may consider starting preventive treatment. Frequent use of acute medications can cause a new type of headache known as medication adaptation headache. For more information about medication adaptation headache, click here.

Acetaminophen, Aspirin and Caffeine

Ex. Excedrin

How Does It Work?

Aspirin is an NSAID which helps decrease inflammation and pain.
Acetaminophen also decreases inflammation and pain and is thought to elevate the pain threshold.
Caffeine narrows the blood vessels in the brain, acts as a pain reliever and increases the absorption of acetaminophen and aspirin.

Together, the 3 components of this medication help to combat migraine attacks. It is taken orally (by mouth).

Side effects

Nausea, vomiting, insomnia, nervousness, jitteriness, and others

Caution

Medications that contain NSAIDS and acetaminophen should not be taken 15 or more days per month. Frequent use can lead to medication adaptation headache.
Inform your healthcare provider if you have liver, heart or kidney disease, a history of GI ulcers or GI bleed as well as high blood pressure.
Avoid using other medications that also contain acetaminophen or NSAIDS.
This medication contains almost as much caffeine as a cup of coffee. Limit caffeine use when using this medication.

Acetaminophen, Butalbital and Caffeine

Ex. Fioricet

How Does It Work?

Acetaminophen is a pain reliever and fever reducer.
Butalbital is in a group of drugs called barbiturates. It relaxes muscle contractions involved in a tension headache.
Caffeine is a central nervous system stimulant. It relaxes muscle contractions in blood vessels to improve blood flow.

Side Effects

Drowsiness or dizziness
Feeling anxious or restless
"Drunk" feeling
Sleep problems (insomnia)

Caution

Medication adaptation headache can occur when this medication is used as few as 5 days per month.
Inform your healthcare provider if you have liver, heart or kidney disease, a history of GI ulcers or GI bleed as well as high blood pressure.
Avoid using other medications that also contain acetaminophen.
This medication contains almost as much caffeine as a cup of coffee. Limit caffeine use when using this medication.

Triptans

Ex. Imitrex, Maxalt, Zomig, Amerge, Frova, Relpax, Axert

There are seven triptans FDA approved for the acute treatment of migraine: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan.

How Do They Work?

Triptans target specific serotonin receptors on the brain’s blood vessels and nerve endings.
Triptans block the neurotransmitter CGRP and narrow blood vessels, which decreases the pain and inflammation of a migraine attack.
Triptans should be taken early in the attack for best results.
Certain triptans may be taken again in 2-4 hours if needed. The seven triptans vary in the onset of action.
They may be taken orally, intranasally or subcutaneously which also affects how quickly they work.
Naproxen in combination with sumatriptan is effective for the acute treatment of migraine.

Side Effects

Side effects may vary based on the triptan taken but may include: chest pain, nausea, dizziness, flushing, tingling and neck pain.

Caution

Tell your healthcare provider if you have a history of heart disease, high blood pressure, impaired liver function, diabetes, peripheral vascular disease or Raynaud’s syndrome
Do not take more than 2 doses in 24 hours
Use of triptans more than 9 times per month can contribute to medication adaptation headache
A person taking triptans may develop serotonin syndrome which is a dangerous but rare condition caused by excessive release of the neurotransmitter serotonin. Tell your healthcare provider if you are taking other medications that increase serotonin levels such as antidepressants, ditans or opioids. Signs and symptoms of serotonin syndrome include nausea, vomiting, agitation, restlessness, confusion, fever, high blood pressure and a rapid heart rate.
Do not take with another type of triptan or ergot alkaloid
Typically avoided in people living with hemiplegic migraine

NSAIDS

Non-Steroidal Anti-Inflammatory Medications (NSAIDS)

Examples: ibuprofen (Advil, Motrin), naproxen (Aleve, Anaprox), ketorolac (Toradol), aspirin, indomethacin (often used for hemicrania continua and paroxysmal hemicrania), diclofenac (Flector, Cambia), and celecoxib (Celebrex, Elyxyb).

How Do They Work?

Reduce pain and inflammation that occurs during a migraine attack.
NSAIDS are generally available over the counter medications and are effective for the acute treatment of migraine.
They are best used for mild to moderate migraine attacks but in some people, may be helpful for severe attacks.
Naproxen used in combination with sumatriptan is often effective for the acute treatment of migraine.
NSAIDS can be administered orally, intravenously, intramuscularly, intranasally and rectally.

Side Effects

GI upset, stomach ulcers, GI bleed, headache, tinnitus, dizziness and drowsiness, and others.

Caution

Medication adaptation headache can occur when NSAIDS are used 15 or more times per month.
Inform your healthcare provider if you have liver, heart or kidney disease, a history of GI ulcers or GI bleed as well as high blood pressure.
Avoid using other medications that also contain acetaminophen and/or NSAIDS.

Ditans

Lasmiditan

Ex. Reyvow

How Does It Work?

Lasmiditan activates a specific serotonin receptor known as 5-HT1F that is found on the nerves. This serotonin receptor is involved in pain pathways. When the receptor is activated, it is able to stop the release of neurotransmitters and block pain.
Since lasmiditan acts on the serotonin receptor on the nerve and not in the blood vessels (like triptans), this acute medication can be used in those who have cardiovascular disease, high blood pressure, diabetes and stroke.

Dosage

50 mg, 100 mg or 200 mg

Side Effects

Dizziness and lightheadedness (increases with higher doses), fatigue, paresthesia (“pins and needles”), sedation, nausea, vomiting and muscle weakness

Caution

Lasmiditan is a controlled substance and must be prescribed by a healthcare provider. There is a driving restriction, therefore people should not drive or operate heavy machinery for eight hours after taking the dose.
This medication should not be used more than 9 times per month because it can contribute to medication adaptation headache.
Do not take this medication more than one time in a 24-hour period.
A person taking ditans may develop serotonin syndrome which is a dangerous but rare condition caused by excessive release of the neurotransmitter serotonin. Tell your healthcare provider if you are taking other medications that increase serotonin levels such as antidepressants, triptans or opioids. Signs and symptoms of serotonin syndrome include nausea, vomiting, agitation, restlessness, confusion, fever, high blood pressure and a rapid heart rate
Inform your healthcare provider if you are on medications that lower your heart rate such as beta blockers.

Ergot Alkaloids

Ex. Dihydroergotamine (Migranal, DHE 45, Trudhesa) and Ergotamine (Cafergot, Ergomar, Migergot)

Ergot alkaloids are typically used for moderate to severe migraine attacks.

How Do They Work?

Ergot alkaloids bind to serotonin, alpha-adrenergic and dopamine receptors in the brain. They also constrict blood vessels and decrease inflammation by inhibiting CGRP.
Ergotamine is often used in combination with caffeine because caffeine helps increase the absorption of the medication and can help to speed up the time it takes to work. It can be administered orally, intranasally, subcutaneously, intramuscularly, or rectally (as a suppository). Ergotamine is rated as “probably effective” for the acute treatment of migraine.
Dihydroergotamine (DHE) is rated effective for the acute treatment of migraine. DHE can be given intravenously, intranasally, subcutaneously or intramuscularly.

Side Effects

Nausea, chest pain, cramps, insomnia, vomiting and more

Caution

Tell your healthcare provider if you have a history of heart disease, high blood pressure, impaired liver function, diabetes, peripheral vascular disease or Raynaud’s syndrome as these medications are typically avoided.
Inform your healthcare provider if you are taking antibiotics, antifungals or HIV medications.
A person taking ergot alkaloids may develop serotonin syndrome which is a dangerous but rare condition caused by excessive release of the neurotransmitter serotonin. Tell your healthcare provider if you are taking other medications that increase serotonin levels such as antidepressants, triptans, ditans or opioids. Signs and symptoms of serotonin syndrome include nausea, vomiting, agitation, restlessness, confusion, fever, high blood pressure and a rapid heart rate.
Do not take ergots within 24 hours of a triptan.
Avoid in people living with hemiplegic migraine or migraine with brainstem aura.
Use of ergots 10 or more times per month can contribute to medication adaptation headache.

Steroids

Ex. Prednisone, Prednisolone, Methylprednisolone (Medrol)

Steroid medications may be prescribed during status migrainosus, also known as a migraine attack that lasts 72 hours or longer. They are typically used after trialing other acute therapies.

How Do They Work?

Steroids decrease inflammation that occurs during the migraine process.

Dosage

The dose may vary but is often prescribed as a taper, meaning a person may begin with a higher dose and slightly decrease the dose each day per the healthcare provider's recommendations.

Side Effects

Weight gain, difficulty falling or staying asleep, restlessness, high blood pressure, elevated blood sugars, sweating, dizziness, headache, swelling and more. A rare side effect is avascular necrosis of bone.

Caution

Those with diabetes, people with hypertension or uncontrolled hypertension, cardiovascular disease, low potassium levels, mental health disorders, eye conditions, during pregnancy and more.

Timolol Eye Drops

Timolol Maleate Eye Drops

Ex. Timoptic

Used "off-label" for the acute treatment of migraine.

How Does It Work?

It is unknown how beta blockers help with the acute treatment of migraine but it is thought they block the stimulating or activating effects of a hormone called adrenalin. They may make the nervous system "less excitable" for someone living with migraine.

Dosage

0.5% solution typically prescribed. One eye drop may be administered to each eye at the first onset of migraine. A second set of eye drops may be needed if there is no improvement within 10-15 minutes. Maximum dose is 4 eye drops in 24 hrs.
Reminder: Remove contact lenses prior to using eye drops.

Side Effects

Burning, stinging, redness, discharge of the eye and/or blurred vision or double vision.

Caution

Heart disease, asthma, changes in blood sugars, nasal pathology, slow or irregular heartbeat; previous eye conditions, surgery or infections; concomitant use of beta blockers and other blood pressure medications and more.

Download the Migraine Diary

Track date, time, symptoms, intensity, what you were doing and what you did to help treat your migraine attack

Download Diary

Preventive Treatments

Who is a Candidate for Preventive Treatment?

A study found that 38% of those with episodic migraine would benefit from preventive therapy. Based on the American Headache Society’s 2021 Consensus Statement, preventive therapy is recommended for those who experience attacks that interfere with daily life despite acute treatment, prefer to be on a preventive treatment regimen, or need to take acute treatments too frequently.

Preventive therapy should be considered when someone has four or more headache days per month or has two headache days with significant disability. Your healthcare provider will assess your health history, comorbid conditions, and other factors to choose a preventive treatment. Finding a preventive treatment that is effective and has tolerable side effects involves trial and error. It is best to try one treatment at a time to determine if there is a positive or negative response. Some treatment options do work best as combination therapies so adding another therapy may be beneficial. Always consult with your doctor if you plan to use multiple therapies, even if they are over-the-counter.

Preventive Treatment Options

Many of the medications commonly FDA-approved for migraine prevention were actually originally intended for other medical conditions such as high blood pressure, depression, epilepsy, or cosmetic changes (ex. wrinkles). Typically the medications are prescribed in lower doses for migraine than they are for the conditions they were originally intended for.

More recently, CGRP monoclonal antibodies and gepants have been approved for the acute and/or prevention of migraine. Many neuromodulation devices are also cleared by the FDA for the acute and/or preventive treatment of migraine.

There are also many medications used “off-label” for migraine treatments that are not FDA-approved for migraine such as certain antidepressants, vitamins, supplements and more.

Preventive Treatments Need to be Taken Regularly

“Start low and go slow”

Preventive medications may be started at a low dose to minimize side effects and your provider will discuss how to slowly increase the dose until the desired dose is reached.

Many medications and other treatments should be trialed for 8-12 weeks to determine if they work or not.
CGRP monoclonal antibodies that are given monthly should be continued for 3-6 months to determine if they are effective.
CGRP monoclonal antibodies that are given quarterly should be assessed at 6 months to determine if they are working properly.
Some people with refractory migraine who use CGRP monoclonal antibodies note improvement in headache days later than the study data.

If you are experiencing side effects or would like to discontinue your treatment, please consult with your clinician. Some medications need to be tapered or weaned off slowly to avoid unpleasant side effects. Sometimes lowering the dose minimizes side effects but still offers some improvement for migraine.

Preventives Aim to Reduce Severity and Frequency

Migraine preventive treatments do not prevent all migraine attacks but can work to reduce the frequency, severity, and disability of attacks.

Preventive treatment is considered a success if it reduces both the number of migraine days you have and the severity of your attacks by at least 50 percent, without intolerable side effects.

Inform Your HCP On Upcoming Life Events

It is important to let your provider know if you are pregnant, plan to become pregnant, or use hormonal contraception (i.e. birth control, IUD) because of medication interactions.

Preventive Treatments Are NOT Forever

If a preventive treatment works well, then it is typically continued for several months (usually 6-12 months). Once a person has better symptom control, a clinician may wean down the dose, until the person is tapered off. Sadly, there is a risk of the headaches returning.

CGRP Monoclonal Antibodies

What is CGRP?

Calcitonin gene-related peptide, or CGRP, is a protein found in the peripheral and central nervous systems. Studies have proven that CGRP levels are higher during a migraine attack and lower between attacks. CGRP causes inflammation, blood vessel swelling and dilation. CGRP also sends pain messages to the brain during a migraine attack.

Gepants and CGRP monoclonal antibodies are two new medication classes that are designed to target CGRP or its receptors.

What Are Anti-CGRP Monoclonal Antibodies?

Antibodies are naturally produced by the immune system in response to a harmful substance known as an antigen. Scientists have been able to create antibodies that are similar to the ones your body makes. These are known as monoclonal antibodies. Anti-CGRP monoclonal antibodies help prevent migraine by targeting the CGRP signaling pathway. These new medications block either the CGRP protein or its receptor.

What CGRP Monoclonal Antibodies Are There?

There are currently four different FDA-approved CGRP-blocking monoclonal antibodies used to treat migraine: erenumab, galcanezumab, fremanezumab and eptinezumab.

Erenumab is the only monoclonal antibody that targets the CGRP receptor. It is given as a monthly subcutaneous injection. The dose is either 70 mg or 140 mg.

The other three monoclonal antibodies attach to the CGRP protein and block it from binding to the receptor.

Fremanezumab is a monthly or quarterly subcutaneous injection (225 mg or 675 mg).

Galcanezumab is a monthly subcutaneous injection (initial dose 240 mg, then 120 mg).

People with migraine can use the autoinjector at home. They should be counseled on the small risk of hypersensitivity and allergic reactions and the proper steps to get help if needed (ex. call 911 and get treatment right away). The antibodies can be injected subcutaneously into an arm, leg, or abdomen.

Eptinezumab is the only monoclonal antibody that is administered intravenously. A single intravenous dose of eptinezumab (100 mg or 300 mg) is given every 3 months. For more information on this monoclonal antibody click here.

Who Should Use These Medications?

They have all been studied in people with episodic or chronic migraine. They have been shown to be effective for all migraine types as well as medication adaptation headache. They are all FDA-approved for people 18 years or older. Insurance coverage varies and may require two other preventive medications failing prior to getting covered.

What Are The Risks of These Medications?

Monoclonal antibodies are not currently associated with any drug interactions. Patients who use monoclonal antibodies do not have to stop taking any of their current preventive or abortive medications or other treatments.
These medications are also not associated with carcinogenesis or genetic interference.
The injection of monoclonal antibodies is relatively painless but there can be a burning sensation for some people. Constipation is one of the most common side effects. A stool softener may be helpful but a healthcare provider should be consulted. Hair loss has also been anecdotally reported after the use of some CGRP-blocking monoclonal antibodies. High blood pressure is another possible side effect.
Monoclonal antibodies do cross the placenta and appear in breast milk.
The long-term effects of blocking CGRP in a developing fetus or child is not clear. If a woman is planning a pregnancy, she should discontinue monoclonal injections 6 months prior to stopping contraception.
The FDA has a pregnancy registry for each of these medications. If a woman has a baby while on this medication, this database will collect information about the medication risks.

High Blood Pressure Medications

High Blood Pressure Medications for Migraine

Beta-blockers, angiotensin II receptor blockers (ARBs), and ace inhibitors are used to treat high blood pressure but have also been found to be effective for migraine prevention. Propranolol is FDA-approved for migraine prevention. Other blood pressure medications may be used “off-label” for migraine. Recent studies have found that calcium channel blockers such as verapamil showed no benefit compared to placebo.

How Do Beta Blockers Help Migraine?

Beta-blockers are first-line treatments used to help prevent migraine attacks. They affect the blood vessels in the brain, make the nervous system less excitable and increase activity in the hypothalamus.

Propranolol (60-240 mg/day)*, metoprolol (25-200 mg/day), atenolol 100 mg/day (50-200 mg), timolol (10-15 mg/day), nadolol (40-80 mg/day, up to 240 mg/day)
Timolol also has an eye drop solution that can be used as an abortive option. See abortive treatments for more information.
Side effects: low heart rate, low blood pressure, activity intolerance, fatigue, erectile dysfunction, vivid dreams, airway bronchospasm, depression and more.
Cautioned in those who are pregnant and/or have asthma, diabetes, circulation issues, COPD, low blood pressure, heart block and more.

How Do Angiotensin II Receptor Blockers (ARBs) Help Migraine?

Angiotensin II receptor blockers (ARBs) are thought to help prevent migraine attacks because they constrict the blood vessels in the brain and decrease the number of inflammatory proteins.

Candesartan - 16 mg/day
Side effects: high potassium, headache, dizziness, abnormal kidney levels, cold symptoms and more.

How Do ACE Inhibitors Help Migraine?

ACE inhibitors are thought to help prevent migraine attacks by constricting the blood vessels in the brain and decreasing the number of inflammatory proteins.

Lisinopril - 20 mg/day
Side effects: low blood pressure, cough, fatigue, dizziness, headache, decreased or cloudy urine, blurred vision and more.

Anti-Seizure Medications

Anti-Seizure Medications for Migraine

It is unknown exactly how anti-seizure medications help prevent migraine attacks. It is thought that these medications calm hyper-excitable nerve cells, or neurons, in the brain.

Topiramate

Topiramate (Topamax) is FDA-approved for migraine and is commonly used as a first-line medication for prevention.

Dose: 25 mg/day may be recommended to be administered nightly for the first week. The dosage may be increased weekly by increments of 25 mg per the provider's recommendations. 100 mg/day administered in two divided doses is typically the recommended dose.
Side effects: tingling in the hands and feet, nausea, vomiting, diarrhea, stomach pain and cramps, fatigue, sleepiness, brain fog, hair loss, change in the way foods taste, weight loss, dizziness, loss of appetite
Consult your doctor if you have lower back pain or pain with urination or other signs of kidney stones.
Report to your doctor a new onset of blurred vision and eye pain as this may be a sign of acute angle closure glaucoma which needs immediate medical attention. Do not take this medication if you have a history of glaucoma.

Divalproex Sodium

Divalproex sodium (Depakote) is FDA-approved for migraine prevention and is commonly used as a first-line medication for migraine prevention.

The typical recommended starting dose is 250 mg twice daily, thereafter increasing to a maximum of 1,000 mg/day as needed, as prescribed by a healthcare provider.
Side effects: drowsiness, nausea, abdominal pain, diarrhea, vomiting, low platelet count, tremors, dizziness, double vision, weight gain, tiredness, problems with walking or coordination, headache, weakness, tremor, increased appetite or loss of appetite and hair loss.
Divalproex can cause serious side effects including pancreas inflammation (pancreatitis) and damage to the liver. Healthcare providers should monitor liver function and blood counts.
A person of child-bearing age who is using this medication will need two forms of contraception given it is a "Pregnancy Category D" medication and has a higher risk of teratogenicity (ability to cause defects in a developing fetus) compared to alternative preventives.

Valproic Acid

Valproic acid (Stavzor) is FDA-approved for migraine prevention

Typical recommended dose: 250 mg twice daily
Side effects: nausea, diarrhea, vomiting, abdominal pain, increased appetite, indigestion, dizziness, tremor, weight gain, back pain, weakness, hair loss and sleepiness.
Valproic acid can cause serious side effects of pancreas inflammation (pancreatitis) and damage to the liver. A healthcare provider should monitor liver function and blood counts.

Gabapentin

Gabapentin may be used off-label for the prevention of migraine. It is thought to act on GABA and glutamate, two neurotransmitters associated with migraine.

Typical recommended dose: 300mg - 2400mg
Side effects: dizziness, drowsiness, lack of coordination, swelling of legs and feet, double vision, difficulty thinking, abnormal eye movements, tremors, jerky movements and more.
Do not drive or operate heavy machinery until you know how this medication affects you.

Levetiracetam

Levetiracetam (Keppra) may be used off-label for the prevention of migraine. Levetiracetam calms hypersensitive pain fibers by binding to the small packages of neurotransmitters within the nerve cells and thereby prevents them from being released and suppresses pain messages.

Typical recommended dose: 500 - 1,000 mg
Levetiracetam has few side effects: dizziness, sleepiness and moodiness.

Warning

Alcohol should be avoided with all anti-seizure medications and any thoughts of suicide should be reported to a healthcare provider or notify the National Suicide Prevention Lifeline at 800-273-8255. Anti-seizure medications may reduce the effectiveness of oral contraception, harm a baby during pregnancy and pass through breast milk. Be sure to consult with your healthcare provider. These medications should never be stopped abruptly, they should be weaned off with guidance from a clinician.

Supplements and Vitamins

Vitamins and Supplements

Although supplements and vitamins are available over the counter, it is very important to consult with a doctor before starting a new supplement or vitamin or changing dosages.

The FDA is not required to check the quality of vitamins and supplements. It is important to ensure that these products are purchased from a reputable company that makes quality supplements. Remember, cheaper does not mean better.

Listen to a podcast on vitamins and supplements for migraine here.

Magnesium

Magnesium is one of the most well-studied supplements used for the prevention of migraine. A study found that there is a correlation between low magnesium levels and migraine, leading to the belief that magnesium deficiency may be a risk factor for migraine. A deficiency of magnesium is thought to play a role in cortical spreading depression which could be responsible for the aura phenomenon associated with migraine.

Some types of magnesium that may be recommended for oral consumption include:

magnesium glycinate
magnesium pidolate
magnesium gluconate
magnesium L- threonate

Typical Recommended Dosage: 200 - 1200 mg daily (common: 400 - 500 mg)

Side Effects: nausea, abdominal cramping, diarrhea.

Topical administration of magnesium chloride is another option and may be beneficial for those who experience gastrointestinal symptoms from oral medication or live with a gastrointestinal disorder. Some forms of magnesium have a relaxing effect and may be best taken in the evening to help support sleep.

Interactions: Can lower blood pressure and interact with some heart medications, diuretics, antibiotics (aminoglycosides) and muscle relaxants.

Riboflavin

Riboflavin, also known as B2, is a vitamin that is found in foods such as organ meats, fortified breakfast cereals, oats, dairy and more. It is unclear how this B vitamin helps with migraine but it may be because riboflavin helps with energy metabolism of the cells and decreases certain neuro-inflammatory substances. People living with migraine have been found to have lower levels of riboflavin compared to those without migraine. A study found that supplementing with 400 mg of riboflavin decreased the number of headache days compared to placebo but more studies are needed.

Typical Recommended Dosage: 400 mg daily

Side Effects: Bright yellow urine and nausea.

Interactions: Can interact with anticholinergics, phenobarbital and probenecid.

Coenzyme Q10

Coenzyme Q10, also known as CoQ10, is a compound that is present in almost every cell in the body and is largely responsible for energy production of the cells. Coenzyme Q10 may help those with migraine by decreasing inflammation, improving cell energy in the brain and reducing CGRP. A study found Coenzyme Q10 levels to be lower in those with migraine than in those without. A recent review of 6 studies found that Coenzyme Q10 was effective in reducing the duration and frequency of migraine attacks.

Typical Recommended Dosage: 100 mg three times daily, consume with fatty foods for best absorption

Side effects: Upset stomach, rash, poor sleep, headache, dizziness and light sensitivity

Interactions: May interact with blood pressure medicines (especially timolol), blood thinners, cholesterol medicines, insulin, some cancer drugs and tricyclic antidepressants.

Omega-3

Omega-3 is a fatty acid that you must get from your diet as the body does not make it naturally. Omega-3s are thought to be beneficial for migraine because they regulate serotonin levels in the brain, reduce inflammation and decrease the number of inflammatory proteins. Common sources of omega-3 include fatty fish, flaxseed, chia seeds, walnuts and soybeans.

A study found that diets high in omega-3s were able to reduce the frequency and intensity of migraine attacks. The study also found greater results when the diet had high levels of omega 3s and low levels of omega 6s.

Typical Recommended Dosage: It is recommended to consume 250–500 mg of DHA and EPA daily, which are two types of omega-3s.

Feverfew

Feverfew as a migraine preventive is controversial because there is a lack of evidence to support it as a treatment. Feverfew is thought to decrease inflammation, relax smooth muscles in the blood vessels and prevent widening of the blood vessels during a migraine attack. Abrupt discontinuation of feverfew can result in “post feverfew syndrome” and should be tapered with the consultation of a provider. Feverfew should not be used during pregnancy.

Typical Recommended dosage: 6.25 mg three times daily

Side effects: Abdominal pain, diarrhea, mouth ulcers, nausea, vomiting.

Interactions/Precautions: Avoid during pregnancy (risk of miscarriage), combining with aspirin (increases bleeding). Watch for ragweed, chamomile or yarrow cross-sensitivity.

Melatonin

Melatonin is a hormone produced by the brain that controls our sleep and wake cycle. The brain increases the amount of melatonin at night and when it gets dark, and decreases it when it is light out. Melatonin may help migraine by improving sleep, decreasing anxiety, regulating neurotransmitters, decreasing the release of CGRP, and acting as a pain reliever. A study found melatonin to be more effective than placebo and as effective as amitriptyline 25 mg in preventing migraine.

Typical Recommended dose: Varies by person, typically 3 mg prior to bedtime is recommended

Side effects: Drowsiness, fogginess in the morning, dizziness, nausea

Interactions: Can reduce the effectiveness or increase the risk of side effects when used with certain medications (blood pressure drugs, seizure-prevention drugs, antidepressants, anticoagulants, immunosuppressants and birth control medications) and increase blood sugar levels. Certain individuals may have an increased sensitivity to melatonin such as children, shift workers, those with depression, etc.

Vitamin D

Vitamin D is not actually a vitamin. It is a hormone. Vitamin D can help migraine by decreasing inflammation and the amount of nitric oxide (a molecule that widens the blood vessels). Vitamin D also influences the release of dopamine and serotonin in the body. Magnesium may not be absorbed as well if there are low levels of Vitamin D. A review did find a link between low Vitamin D levels and migraine. There was not enough evidence to recommend supplementation in all migraine patients unless there is a Vitamin D deficiency.

The optimal dose for migraine prevention is to be determined.

Side effects: Constipation, nausea, vomiting, weight loss, kidney stones, irregular heartbeat, confusion, chest pain

*If you have heart disease, an irregular heartbeat or kidney problems, please consult your doctor before starting Vitamin D.

Botulinum Toxin

What is Botulinum Toxin?

Botulinum toxin is a neurotoxin that is produced by bacteria known as clostridium botulinum. There are currently four different botulinum toxins available for chronic migraine: onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA and rimabotulinumtoxinB.

Who is Botulinum Toxin Intended For?

OnabotulinumtoxinA was the first to be FDA-approved for the prevention of chronic migraine in adults. It is also currently the most commonly used botulinum toxin for migraine. Chronic migraine is defined as head pain on 15 or more days per month with at least eight of those headaches accompanied by migraine symptoms.

What Does Treatment Look Like?

Treatment consists of 31-39 injections (totaling 155-195 units) delivered into 7 key muscle areas of the head and neck. The toxin relaxes the muscles and is thought to be absorbed by the nerves in the head and neck which may block pain-signaling chemicals known as neurotransmitters. Injections typically work best if administered every 12 weeks. The procedure takes roughly 15 minutes.

Side Effects

Side effects may include neck pain or soreness, headache, pain at the injection site and/or eyelid or eyebrow drooping. A headache may develop within 24 hours of injection. It can take up to 2 weeks to reach full efficacy. It is recommended to try at least three or four sessions for the best results.

Antidepressants

Are Antidepressants Used for Migraine Prevention?

Antidepressants are commonly used to prevent migraine attacks. Although none are approved by the FDA for the treatment of migraine, they have shown positive results in clinical trials. They help stabilize the levels of neurotransmitters in the brain which fluctuate during a migraine attack and in-between attacks.

What are Tricyclic Antidepressants?

Tricyclic antidepressants increase the amount of serotonin and norepinephrine in the brain.

Amitriptyline - Has the best evidence in migraine clinical trials in comparison to the other antidepressants

Typical recommended dose: Starting dose is typically 10 mg daily but may be increased up to 25 mg per day. It is recommended to take it at bedtime.
Side effects: dry mouth, weight gain, sleepiness, brain fog, retention of urine, lightheadedness when standing up, irregular heartbeat, dizziness, constipation, headaches and others.

Nortriptyline - Often prescribed for those who have side effects with amitriptyline and cannot tolerate the medication.

Typical recommended dose: 25 mg at bedtime. It may be increased by 25 mg every week until the desired dose is reached. Max dose 150 mg.
Side effects: Dry mouth, weight gain, drowsiness, dizziness, constipation, changes in sex drive, breast enlargement, nausea, vomiting, diarrhea, increased heart rate, skin rash and more.

*These medications should be avoided in those with glaucoma, heart disease, urinary issues and an enlarged prostate. Caution in those who are pregnant or have diabetes.

What Are Serotonin Norepinephrine Reuptake Inhibitors?

Serotonin Norepinephrine Reuptake Inhibitors (SNRI’s) increase the amount of serotonin and norepinephrine in the brain.

Venlafaxine

Typical recommended dose: Starting dose 37.5 mg then may increase to 150 mg daily. Can be taken in the morning.
Side effects: dry mouth, sexual dysfunction, nervousness, nausea, headache, increased sweating, dizziness, drowsiness and more.

What are Selective Serotonin Reuptake Inhibitors (SSRI's) and Are They Helpful for Migraine Prevention?

Selective Serotonin Reuptake Inhibitors (SSRIs) increase the amount of serotonin in the brain. At this time SSRIs such as fluoxetine and sertraline have not shown effectiveness for migraine prevention but may work well for common migraine comorbidities such as depression and anxiety.

Suicidal Warning

Any thoughts of suicide while on any of the antidepressant medications should be reported immediately to a provider or to the National Suicide Prevention Lifeline at 800-273-8255. These medications should never be stopped abruptly. They should be weaned off with guidance from a clinician.

Memantine

What Is Memantine and Is It Effective For Migraine Prevention?

Memantine is an NMDA receptor antagonist which means it helps reduce abnormal activity and excitation in the brain. Although it is used to help treat the symptoms of Alzheimer’s disease, this medication has been classified as “probably effective” for the prevention of migraine. It is not typically used as a first-line preventive for migraine.

Typical recommended dose: 10 mg - 20 mg daily
Side effects: dizziness, headache, constipation and confusion

Surgical Options

What Type of Surgical Procedures Are Used For Migraine?

There are two types of surgical procedures for migraine, one known as nerve decompression and the other is called a neurectomy.

Nerve decompression surgery: A surgeon removes areas of muscle and tissue that compress the sensory nerves around the head and neck region. These areas are thought to be trigger points for migraine. The surgeon will place fat or a “cushion” around the nerve to avoid re-compression of the nerve thereby relieving pressure. A review of studies on nerve decompression surgery found that 28.3% - 59% of people had complete migraine elimination while 26.5 - 66% of people had >50% reduction of migraine attacks.
Neurectomy: A neurectomy is a procedure that cuts the end of the nerve to prevent it from sending pain signals. The nerve site can vary depending on where the person has pain (supratrochlear, supraorbital, etc). There was one study of 26 patients that had neurectomies for migraine and 100% of people were able to eliminate preventive medication.

More research is needed on surgery for migraine and other medical interventions are generally trialed prior to surgery.

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Diagnostic questions, treatment options, dosages and preventative measures.

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Acute and Preventive Therapies

Gepants

What is CGRP?

Gepants and CGRP monoclonal antibodies are two new medication classes that are designed to target CGRP or its receptors.

What are Gepants?

Gepants are a medication class that are known as CGRP antagonists. This means gepants block the CGRP protein from attaching to its receptor. There are three gepants currently available:

Rimegepant (orally dissolving tablet) - approved for the acute treatment of migraine and the preventive treatment of episodic migraine
Ubrogepant (oral tablet) - approved for the acute treatment of migraine
Atogepant (oral tablet) - approved for the preventive treatment of episodic migraine
Zavegepant (nasal spray) - approved for the acute treatment of migraine

Benefits of Gepants:

They don’t have the same risk of medication adaptation headache as some other migraine and pain relievers.
They are longer and faster acting than some other common migraine medications.
They do not cause blood vessels to constrict, so unlike triptans, they should be safe in those with vascular disease.
They appear to work for patients who did not gain relief from triptans.
While they are best used early in a migraine attack, many still find relief even if it is taken late during an attack.

Who Should Use These Medications?

All FDA-approved gepants have been studied and show efficacy for adults with episodic or chronic migraine. It is safe for all migraine types as well as medication adaptation headache.

Side Effects

Fatigue and nausea are the most commonly reported symptoms.
The long-term effects of blocking CGRP in a developing fetus or child are not clear.
If a person is planning to get pregnant, they should stop gepants 6 months prior to contraception.

Can I Take Gepants With My Other Medications?

There are no known drug interactions with gepants. Patients who use gepants do not have to stop taking any of their current medications, including other acute and preventive migraine medications. Always consult with your doctor before taking a new medication.

Neuromodulation

Remote Electrical Neuromodulation

Ex. Nerivio®

Remote electrical neuromodulation is FDA cleared for the acute treatment of episodic and chronic migraine in people aged 12 years and older. It is also FDA cleared for the prevention of migraine. The device is applied to the upper arm where it stimulates the nerve fibers. These signals travel from the upper arm into the brainstem. This process helps to stop pain messages that occur in the brain during a migraine attack.

This device is worn on the upper arm and secured with the strap provided. It is controlled by an app on a cell phone. For acute treatment, the device is typically used at the onset of an attack and worn for 45 minutes. For preventive treatment, the device is typically worn every other day for 45 minutes. It is generally recommended to set intensity to a strong but not painful level for the entire session.

Side effects: No systemic side effects. Similar incidence of Side Effects in both Nerivio and Placebo groups of studies. Warmth, tingling and itchiness found during Acute study and no Adverse Events found
in the Nerivio group in Prevention study.

*Safety information from Nerivio can be found here.

External Trigeminal Nerve Stimulation (e-TNS)

Ex. Cefaly®

The trigeminal nerve is the largest nerve in the brain and plays a big role in migraine attacks. The external trigeminal nerve stimulation device is worn on the forehead where it stimulates the top branches (supraorbital and supratrochlear nerves) of the trigeminal nerve. It is thought that migraine pain can be interrupted by stimulating the trigeminal nerve.

This is an FDA cleared device for the acute and preventive treatment of episodic migraine in those over 18 years old. As a preventive agent, it is typically used once a day for 20 minutes. It may be used for break-through acute migraine attacks up to 60 minutes per day.

Side effects: Sleepiness, temporary allergic rash or redness on forehead, low-grade headache following preventive treatment and more.

For the user manual/safety information on cefaly, click here.

*This is currently the only neuromodulation device that does not require a prescription.

Non-Invasive Vagus Nerve Stimulation

Ex. Gammacore™

Non-invasive vagus nerve stimulation stimulates the vagus nerve through the skin. The vagus nerve runs from the brain through the face to the abdomen. It is thought that stimulation of this nerve helps block pain signals that cause migraine.

It is FDA cleared for:

acute and preventive treatment of migraine (12 years and older)
acute and adjunctive preventive treatment of cluster headache
acute treatment of hemicrania continua and paroxysmal hemicrania.

The device is placed at the neck where a pulse can be felt. Intensity should be Increased until muscle contractions or lip pulling can be felt. You can schedule a 1:1 video call with a company representative prior to use.

For migraine prevention, the device is typically used for 2 stimulations, 2 times a day for a total of 4 stimulations. Each stimulation is 2-minutes long. The device will automatically stop after 1, two-minute stimulation is completed. If you are using it for prevention you will need to increase the intensity for another stimulation. The first use is typically within 1 hour of waking up in the morning and the second use is typically at night. Be sure to apply the conductive gel that was supplied with the device prior to stimulation.

For acute treatment of migraine, the device is typically used for two 2-minute stimulations at the onset of pain. The instructions encourage a person to wait 10 seconds after each stimulation. If the pain does not resolve within 20 minutes, a person can use the device for two more 2-minute stimulations. The company recommends to use a third time after 2 hours, if you still have pain, for another two 2-minute stimulations.

Side effects: dizziness, redness, application site discomfort, irritation, muscle twitching of face/head/neck or tingling resolving after treatment finishes and more.

Gammacore safety information is located here.

Non-Invasive Combined Occipital and Trigeminal Nerve Stimulation

Ex. Relivion® MG

The non-invasive combined occipital and trigeminal nerve stimulation was cleared by the FDA for the acute treatment of episodic migraine in those 18 or older.

This device is an electronic headset that wraps around the forehead to the back of the head. It has 4 electrodes that stimulate the trigeminal nerve and 2 electrodes on the back of the headset that stimulate the occipital nerves. During use, the device sends signals to both of these nerve pathways. These signals are relayed to the brainstem to provide relief from a migraine attack.

The headset is connected to a cell phone app that stores all the treatment data and can be shared with a health care provider. Treatment times vary for each patient. Proper fitting is critical in receiving an effective treatment. Guided device fittings are offered by the manufacturer and should be scheduled prior to using the device.

Side effects: Scalp numbness, persistent tingling, pain, skin reaction, fatigue, sleep disruptions, dizziness, headache and more.

*Safety information for Relivion can be found here.

Single-Pulse Transcranial Magnetic Stimulation

Ex. SAVI Dual™

Single-pulse transcranial magnetic stimulation is FDA cleared for the acute and preventive treatment of migraine in people 12 years and older. This patient use, central neuromodulation device delivers single low frequency electromagnetic fields directly to the brain to calm the hyperactive nerves thought to be involved in the migraine process. Typically, a preventive treatment regimen includes 4 pulses twice a day, and each treatment takes less than 2 minutes. A 30-day prescription includes unlimited acute and preventive treatments.

*More information about Savi Dual™ can be found here.

Nerve Blocks

Nerve Blocks

How Do They Work?

Nerve blocks temporarily block pain signals from the nerves thereby decreasing pain.
Nerve blocks consist of small subcutaneous injections of a particular anesthetic such as lidocaine or bupivacaine into a specific location of the neck/head region.
Common target locations include: greater occipital nerve, lesser occipital nerve, auriculotemporal nerve, supratrochlear and supraorbital nerves, sphenopalatine ganglion (SPG), cervical spinal roots, and facet joints of the upper cervical spine.

Benefits of Nerve Blocks

Relief from the pain may occur in a few minutes or the start of relief may be delayed over a few hours but can last days, weeks or months.
Nerve blocks are commonly used during pregnancy due to the safety profile of lidocaine.
Nerve blocks can be used as an acute and/or preventive option for migraine.

Side Effects

Infection (rare), dizziness, worsening headache and/or neck pain, numbness, bleeding/bruising and/or pain at injection site and more.

Caution

Active infection, taking blood thinning medications, history of syncope (nearly passing out) with procedures requiring injections and more.

Guides for the Latest Migraine Treatments

CGRP Monoclonal Antibodies

BRAND NAME	AIMOVIG®	AJOVY®	EMGALITY®	VYEPTI®
GENERIC NAME	erenumab-aooe	fremanezumab-vfrm	galcanezumab-gnlm	eptinezumab-jjmr
MANUFACTURER	Amgen/Novartis	Teva Pharmaceuitcals	Eli Lilly & Company	Lundbeck
INDICATION	Preventive treatment of migraine in adults	Preventive treatment of migraine in adults	Preventive treatment of migraine in adults *Also approved for episodic cluster	Preventive treatment of migraine in adults
PRICE & SAVINGS PROGRAMS	List price: $638.77/month Insured patients pay from $0-$128 per month. Savings program: aimovigaccesscard.com	As low as $5 for eligible commerically insured patients with savings program: ajovy.com/savings	List price: $627.60/month Insured patients pay from $0-$354 per month. Savings program: emgality.com/savings	List Price: $1,532.38 for recommended dose every 3 months. Most people do not pay the list price. Savings program: vyepti.com/savings-and-support
DOSAGE	70 mg once monthly or 140 mg once monthly	225 mg monthly or 675 mg every 3 months	240 mg loading dose then monthly 120 mg doses*	100 mg infusion every 3 months *Some may benefit from a 300 mg dose.
EFFICACY *See individual websites for complete study results	~40% of chronic patients and ~50% of episodic patients had their monthly migraine days reduced by at least 50%.	39.2% of chronic patients and 46% of episodic patients had their monthly migraine days reduced by at least 50%.	~61% patients had ≥ 50% reduction in headache days* ~37% patients had ≥ 75% reduction in headache days* ~14% patients had 100% headache day reduction*	Episodic ~45% reduction in average monthly migraine days Chronic: ~48% reduction in average monthly migraine days *100 mg dose, months 1-3
DELIVERY ADMINISTRATION	monthly subcutaneous injection	monthly or quarterly subcutaneous injection	monthly subcutaneous injection	quarterly intravenous infusion
HALF LIFE	28 days	31 days	27 days	27 days
PRIMARY SIDE EFFECTS	Injection site reaction, constipation, allergic reactions	Injection site reaction, allergic reactions	Injection site reaction, allergic reactions	Stuffy nose, scratchy throat, allergic reactions

Download CGRP Antibodies Chart

Gepants

BRAND NAME	Ubrelvy®	Nurtec® ODT	Qulipta™
GENERIC NAME	ubrogepant	rimegepant	atogepant
MANUFACTURER	AbbVie	Biohaven Pharmaceuticals	AbbVie
INDICATION	Acute treatment of migraine	Acute treatment of migraine & preventive treatment of episodic migraine	Preventive treatment of episodic migraine
PRICE & SAVINGS PLAN	As low as $0 for eligible commerically insured patients using savings program: ubrelvy.com/savings	As low as $0 for eligible commerically insured patients using savings program: nurtec.com/savings	As low as $0 for eligible commerically insured patients using savings program: qulipta.com/savings
DOSAGE	50 or 100 mg, as needed Max dose: 200 mg in 24 hours	Acute: 75 mg, as needed Max dose: 75 mg in 24 hours Preventive: 75 mg every other day Max dose: 75 mg in 24 hours	10 mg, 30 mg, or 60 mg, orally once daily Max dose: 60 mg in 24 hours
EFFICACY *See individual websites for complete study results	Measured at 2 hours post-dose Pain Relief: 60.7% at 50 mg 61.4% at 100 mg Pain Free: 19.2% at 50 mg 21.2% at 100 mg	Measured at 2 hours post-dose Pain Free: 21.2% at 75 mg Pain Relief: 59.3% at 75 mg Prevention: 30% reduction in weekly migraine days at Week 1	53% migraine day reduction in week 1 54% migraine reduction across 12 weeks
HALF LIFE	5-7 hours	11 hours	11 hours
PRIMARY SIDE EFFECTS	nausea and sleepiness	nausea, stomach pain, indigestion	nausea, constipation, decreased appetite and fatigue

Download GEPANTS Chart

Devices

BRAND NAME	CEFALY®	Nerivio®	gammaCore Sapphire™	Relivion® MG	SAVI Dual™
MANUFACTURER	CEFALY Technology	Theranica	electroCore	Neurolief	eNeura Inc
INDICATION *unless otherwise explained, indications are for people 18+ years old	Acute and Preventive Treatment of Episodic Migraine*	Acute and Preventive Treatment of Episodic and Chronic Migraine Approved for people aged 12 years and older	Acute & Preventive Treatment of Migraine & Cluster Migraine approval for people aged 12 years and older. Also approved for other headache types	Acute Treatment of Episodic Migraine*	Acute and Preventive Treatment of Migraine Approved for people aged 12 years and older
PRICE	$379 for a device $25 - $33 for additional electrodes for more uses (Available w/o prescription)	Price varies dependent on Insurance Coverage. Nerivio Savings Program offers first device for $49 (18 treatments) to eligible and insured patients. Contact Nerivio Cares at 866-637-4846 for additional information.	Contact Customer Service at 1.888.903.2673 as pricing varies. Patients may complete a telehealth consult for a prescription & purchase at www.gammaCore.com.	$200 for the Relivion Therapy 90-Day Trial Program. If the trial program is successful, a patient can continue with Relivion for as low as $75 per month. Please go to Relivion.com for full detail.	Varies depending on insurance. Contact 1-833-499-9300 (option 1) for additional information.
EFFICACY *See individual websites for complete study results. Stats given for migraine only.	Acute: 57% had resolution of their most bothersome symptom and 25% achieved complete pain freedom Prevention: People experienced a reduction in migraine days, pain severity & acute drug intake	Acute: 67% of patients 18+ and 72% of patients aged 12-17 achieved pain relief Prevention: 4 Monthly Migraine Day Reduction. Over 50% of patients saw equal to or greater than 50% reduction in moderate to severe headache days.	Acute: 41% pain relief at 2 hrs Preventive: 4.6 fewer headache days/month & 5.5 fewer for those with migraine with aura	76% of patients achieved headache relief at 2 hours. 46% of the patients reached complete pain freedom.	Acute: 39% pain freedom at 2 hours. Sustained pain freedom up to 48 hours. Preventive: 46% experienced a >50% reduction in headache days and medication use.
DELIVERY ADMINISTRATION	On Forehead Acute: 60 minutes at onset or during migraine Preventive: 20 minutes daily	Acute: Treat at the onset of migraine for 45 minutes Prevention: Treat every other day for 45 minutes Directions: Set intensity to a strong but not painful level and leave there for 45 minute treatment. May be used more than once in a day.	Acute: A 2-minute stimulation as directed on neck, up to 24 stimulations per day. Preventive: Two, 2-minute stimulations 3 times a day (morning, mid-day & night)	Acute: Treat at onset of headache for 40 minutes. Directions: The sensation should be strong enough to relieve the headache, but comfortable enough for prolonged treatment.	Delivered to the back of the head for <1 minute. Acute: As often as needed for pain freedom or relief. Preventive: Daily treatment to reduce migraine days and medication use.
SIDE EFFECTS	Sleepiness, temporary allergic rash or redness on forehead, low-grade headache following preventive treatment	No systemic side effects. Similar incidence of side effects in Nerivio and placebo groups. Warmth, tingling and itchiness found during acute study and no adverse Events found in the Nerivio group in prevention study.	Application site discomfort, irritation, muscle twitching of face/head/neck resolving after treatment finishes	Scalp numbness, persistent tingling, pain, skin reaction, fatigue, sleep disruptions, dizziness, headache	Most common adverse events resolve immediately: light headedness, tingling, and tinnitus. No serious adverse events reported.

Download Devices Chart

Other Therapies

Trigger Point Injections

Trigger points are focal areas of muscle spasm, often located in the upper back and shoulder areas that can contribute to headache and myofascial pain. A trigger point injection involves the injection of medication (steroids, saline and/or anesthetic medicine) directly into the trigger point. With the injection, the trigger point is made inactive and the pain is alleviated. Usually, a brief course of treatment will result in sustained relief. Injections are typically given in a medical office and often work within a few minutes. Several spots may be injected in one visit.

Trigger point injections can be used to treat a number of conditions including migraine, fibromyalgia, tension headache, and myofascial pain syndrome.

Side Effects

Infection, nausea, dizziness, numbness, redness, bleeding/bruising and/or pain at injection site and others.

Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) addresses the way thoughts (cognitions) reciprocally interact with our actions (behaviors). This psychological treatment targets maladaptive behavioral and cognitive responses to pain, social and environmental factors.

First, therapy aims to identify negative thoughts or beliefs. A person will learn how to challenge, restructure and replace negative thought patterns with realistic and positive thoughts. This may help a person provide control over thinking and decrease distress with decision-making.

Second, therapy focuses on changing behavioral habits. A therapist will identify and assess problematic behaviors such as sleeping patterns, eating habits, medication usage and more. Then, the therapist will educate the patient about stress management techniques, relaxation therapies, and problem-solving skills.

Together, combining cognitive and behavioral therapies can help a person emotionally, physically and behaviorally. CBT can help people with migraine, headache, or other pain conditions by teaching the individual skills that increase the ability to cope with pain and reduce headache-related psychological distress.

Each visit with a CBT practitioner is known as a session. The number of CBT sessions can vary based on the patient. CBT has proven to be effective for the treatment of migraine, especially in combination with preventive medications.

For more information on cognitive behavioral therapy view our blog.

Cannabis

Cannabis is a plant that contains over 500 cannabinoids and 104 compounds. Two types of cannabis are hemp and marijuana. Hemp contains less than 0.3% THC and contains higher concentrations of CBD, while marijuana contains greater than 0.3% THC and has smaller concentrations of CBD.

THC vs. CBD

THC is known for its psychoactive properties but may be used for nausea, pain relief, insomnia and as an appetite stimulant. There are many different strains of THC, some are more likely to induce relaxation while others increase focus and concentration. Some strains are more supportive of treating pain while others may not be or have the potential to intensify preexisting mental health conditions such as anxiety. CBD is thought to decrease pain, inflammation and anxiety without a psychoactive or “high” effect. Unfortunately the most effective strain of cannabinoids to treat migraine and headaches are unknown.

Ways People Consume Cannabis

Inhalation by smoking or vaping is the quickest way to achieve results. According to the CDC, vaporized THC has been linked to EVALI (E-cigarette or vaping-associated lung injury) due to additives in the product. Cannabis can also be consumed as an edible, a topical application, sublingually (under the tongue), or as a transdermal patch. It is typically recommended to start CBD at a low dose of around 5 mg per day and slowly increase it to 20-50 mg per day. For THC, it is common to begin around 2.5 mg-5 mg. Currently, this therapy is not covered by insurance and may be costly for quality products. Always consult with a healthcare provider prior to starting a new treatment or changing dosages.

Precautions/Side Effects

CBD must be used with caution with drugs that induce the liver enzymes CYP3A4 or 2C19 such as blood thinners, anti-seizure medications, antiarrhythmics and thyroid medications. Cannabinoids should be avoided in children and during pregnancy because of concerns about brain development and lowering a child’s potential IQ. For a small number of users, there are serious risks of hyperemesis syndrome, chronic psychosis, unveiling underlying schizophrenia, and an estimated 9% risk of addiction. Typical cannabinoid side effects include drowsiness, increased appetite, diarrhea, dry mouth, and elevations in transaminase. Any user of THC should avoid driving and use of heavy mechanized equipment because of potentially impaired attention and heightened anxiety.

Please note this description is for medical cannabis. Cannabis is still considered federally illegal and laws vary from state to state.

Relaxation Training

Relaxation Therapy

Relaxation training focuses on achieving a state of emotional and physical relaxation. There are different types of relaxation training such as progressive muscle relaxation, guided imagery, mindfulness and autogenic relaxation. Relaxation training is commonly used with other biobehavioral therapies such as biofeedback or cognitive behavioral therapy. It may be effective for the prevention of migraine.

Progressive Muscle Relaxation

A person tenses certain muscle groups in the body and then releases the tension to notice differences in how the muscles feel when they are relaxed.

Guided Imagery

Involves using all five senses and the imagination to think about a calm, peaceful setting in order to create a sense of relaxation.

Mindfulness

The practice of using self awareness to observe thoughts, feelings and sensations in the body.

Autogenic Relaxation

Directs attention to a state of calmness, while repeating phrases to create a sensation of warmth and heaviness in the body. It also involves paying attention to the heartbeat and breath.

Biofeedback

Biofeedback is a behavioral therapy technique used to control bodily functions. A healthcare professional places sensors on a patient and connects them to a monitor that displays live readings of their heart rate, blood pressure, muscle tension, respiratory rate, brain activity, body temperature and perspiration (sweating) in relation to the patient's thoughts and feelings. Based on this data, a provider can teach a patient how to change the way their body responds to thoughts, pain or stress. Over time, a patient can learn to better control their body's functions (heart rate, respiratory rate, etc.) and manage symptoms.

Each biofeedback session may last 30-60 minutes. Biofeedback may be effective for migraine prevention and has been shown to decrease the frequency and severity of migraine attacks. Studies have found the best efficacy when used in combination with a migraine preventive medication.

Daith Piercing

Daith piercing is a type of ear piercing that is located in the innermost cartilage fold that is right above the ear canal. Some people report reduced pain after a daith piercing but it is likely due to the placebo effect. There is no scientific research at this time to indicate daith piercing can be beneficial for migraine.

Side Effects

Infection, skin reactions, keloids and others.

Ketamine

Ketamine blocks an important neurotransmitter in the brain called glutamate from reaching the N-Methyl-D-Aspartate (NMDA) receptor which is involved in pain. There is robust medical literature for the use of ketamine to treat refractory depression which can often be comorbid with migraine. Ketamine may be used intravenously during an inpatient or ambulatory healthcare setting for refractory migraine or as a nasal spray. It is typically used as a “last resort” or after other therapies are ineffective.

Acupuncture

Acupuncture is an alternative medicine practice that inserts fine needles into the skin by a trained practitioner. It aims to target a person’s meridians or “the flow of energy” throughout the body. Acupuncture may be used for people with migraine and/or tension headache.

Although it is not clear how exactly acupuncture helps with migraine and tension headache, it is thought that it stimulates the release of endorphins, endogenous opioids and other substances that help decrease the pain response.

A review of 22 clinical trials on acupuncture as a preventive treatment for episodic migraine found that acupuncture decreases the frequency of headache and may be as effective as preventive treatment. More research on acupuncture and headache disorders is needed.

It is important to note that combination therapies are more effective than any single approach for maintaining long-term gains and managing migraine. The choice of therapies is individualized based on patient factors, access to care, cost, and patient values and preferences.

Laser Therapy

Laser therapy uses red and infrared laser light to affect the skin surface and the structures deeper inside of the body. When the light gets absorbed by components inside of the body, it helps to increase circulation in the tissues, increase the delivery of oxygen from the blood to the tissues, and increase the processing of oxygen to produce cellular energy so the cell can work more efficiently.

This page has been medically reviewed by Andrea Murphy MSN, APRN, ANP-BC, NEA-BC, AQH.

Caution: This information is NOT intended to endorse drugs or recommend therapy. Only your doctor can decide which medications are right for you. Never stop, start or change the way you use a prescription medicine without first consulting your doctor. Not all side effects are described. Call your doctor or consult your pharmacist for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

The contents of this page are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The dosages provided are all stating what is typical for an individual but it is important to always consult with a medical professional to determine what dose is best for you. The list of side effects for each medication is not exhaustive. AMD does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.