Migraine Treatments

What Can We Do About Migraine?

If you live with migraine, there can be relief.

There are two different approaches;

  1. treating the symptoms when they occur (acute intervention)
  2. taking medication routinely to reduce the intensity and frequency of migraine attacks (preventive or prophylactic medications)

If you are currently using medication to manage your migraine disease, you may want to use a Migraine Medication Diary to track its effectiveness.

Download the Migraine Diary

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

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
Price & Savings Plan List price: $603.18/month
$5 or less per month for up to 12 doses for eligible commercially insured patients with program: aimovig.com/paying-for-aimovig
As low as $5 for eligible commerically insured patients with savings program:
ajovy.com/savings
List price: $603.60/month
As low as $0 for up to 12 doses for eligible commercially insured patients with program: emgality.com/savings
As low as $5 per infustion every 3 months for eligible commerically insured patients with 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 patients my 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% reduction in headache days
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

GEPANTS and DITAN

Brand name Ubrelvy™ Nurtec™ REYVOW™
Generic Name ubrogepant rimegepant lasmiditan
Manufacturer Allergan Biohaven Pharmaceuticals Eli Lilly & Company
2020 Co-Pay Savings Program As low as $10 per for 10 tablets for up to 12 refills for eligible commercially insured patients using savings program: ubrelvy.com/savings As low as $0, limited to one 8-tablet prescription per month for eligible commercially insured patients with savings program: nurtec.com/savings-support As low as $0 for 8 pills for up to 12 months for eligible commercially insured patients with savings program: reyvow.com/savings-support
Prior authorization is needed after 1 fill.
Dosage 50 or 100 mg, as needed
Max dose is 200 mg in a 24 hr period
75 mg, as needed
Max dose is 75 mg in a 24 hr period
50,100 or 200 mg, as needed
Max dose is one dose in a 24 hr period
Efficacy
*See individual websites for complete study results

Measured at 2 hours post-dose
Pain Free: 19.2% at 50mg |21.2% at 100mg
Pain Relief: 60.7% at 50mg | 61.4% at 100mg

Measured at 2 hours post-dose
Pain Free: 21.2% at 75mg
Normal Function: 38.1% at 75 mg
Pain Relief: 59.3% at 75mg

Measured at 2 hours post-dose
Pain Relief: 56% at 50mg | 61% at 100mg | 61% at 200 mg
Pain Free: 28% at 50mg | 31% at 100mg | 39% at 200 mg

Delivery Administration oral tablet orally dissolving tablet oral tablet
Half Life 5-7 hours 11 hours 5.7 hours
Primary Side Effects nausea and sleepiness nausea dizziness, sleepiness, numbness, feeling tired, tingling
Warnings none provided hypersensitivity reactions, including dyspnea and rash driving impairment, central nervous system depression, serotonin syndrome, medication overuse headache

Devices

Brand name CEFALY Nerivio® gammaCore Sapphire™
Manufacturer CEFALY Technology Theranica electroCore
Indication
*unless otherwise
explained, indications are
for patients 18+ years old
Acute and Preventive Treatment of Episodic Migraine Acute Treatment of Episodic Migraine Also approved for children 12 years and older Acute and Preventive Treatment of Migraine and Cluster
Price $399 for a device Additional electrodes range from $25 - $33 for more uses (Available over-the-counter) As low as $10 co-pay, dependent on insurance. $99 out-of-pocket cost for uninsured $575 (24 stimulations/day for 31 days) Patients may be eligible for assistance ≤$100 for ≤12 months, Cost-free options for veterans & active military
Efficacy
*See individual websites for complete study results. Stats given for migraine only.
Acute: 79% of patients reported pain relief after 1 hr* Preventive: 38% of patients had at least a 50% reduction in migraine days 67% of patients achieve pain relief at 2 hours Acute: 41% pain relief at two hours after 8 minutes of stimulation
Preventive: 2.27 fewer migraine days
Delivery Administration On Forehead, Acute: 60 minutes at onset or during migraine Preventive: 20 minutes daily Start within 1 hour of migraine onset, on outer upper arm. Set intensity to a level that is strong but not painful and keep it at that setting for the 45 minute treatment Acute: Two 2-minute stimulations at symptom onset, on neck. Can be repeated 20 mins. and 2 hours from start of 1st treatment.
Preventive: 3 treatments (morning, mid-day and night) consisting of 2 consecutive two-minute stimulations daily
Side Effects May feel sleepiness during use, temporary allergic rash on forehead, or low-grade headache following preventative treatment Warmth, itching, tingling or mild pain in the arm, shoulders, or neck, muscle spasm, temporary numbness in the arm or hand Application site discomfort, irritation, muscle twitching of face/head/neck resolving after treatment finishes

Preventive Treatments

Since many migraine disorders are more chronic, treatment with preventive agents often offers the best relief to sufferers, but finding an agent that has tolerable side effects and is effective involves a trial and error process. It is usually most effective and safe to trial one medicine at a time, although some medications work well together in low doses.

Don’t be afraid to try these medicines

These drugs were first used for many other medical purposes, such as prevention of high blood pressure, depression or epilepsy. These medicines act on the transmission of information in our nervous system and, at the low doses needed for preventing migraine, they usually have little or no other effects.

There are no firm rules on how any particular medication should be used. The Food and Drug Administration (FDA) has approved only four of these drugs for prevention of migraine: propanolol, timolol, divalproex sodium (Depakote) and topiramate (Topamax), but that does not mean that there has not been a great deal of research and success with a much larger number of migraine preventive drugs.

A beta blocker or calcium channel antagonist may be more appropriate for a patient with hypertension, while a tricyclic antidepressant may benefit a migraine patient who is depressed or having difficulty sleeping.

Preventive medicines need to be taken daily

These medicines should be started at a low dose to minimize side effects. The dose should be regularly increased in small amounts until an ideal dose is reached.

Many medicines need be taken for 4-12 weeks to know if it works or not. Discuss with your physician the option to discontinue any medication that causes an unpleasant side effect.

Don’t expect too much

Migraine preventative treatments often do not completely prevent all migraine symptoms, but they aim to reduce the frequency and severity of symptoms.

Your best preventive medicine will depend on your medical condition

You need to discuss with your health professional issues about pregnancy, weight, sleep disturbances, blood pressure and more.

Preventive medicines are not forever

**If a preventive treatment works well, that medication can then be continued for several months (usually 6-12 months). With better symptom control one may want to wean down the dose. When stopping a preventive medicine, there is a risk of the headaches returning. It is unusual for migraine frequency suddenly to bounce back again during weaning down. Migraine illness varies during a lifetime and the use of preventive medication may have to be adjusting for those variations.

This information is NOT intended to endorse drugs or recommend therapy. While these reviews might be helpful, they are not a substitute for the expertise, skill, knowledge and judgment of healthcare practitioners in patient care. 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.

CGRP Blockers

How do CGRP blockers work?

Calcitonin gene-related peptide, or CGRP, is a neurotransmitter found in both the peripheral and central nervous systems. It has been shown to be released during a migraine attack. It carries pain signals to the brain, particularly of the trigeminal nervous system. It also causes blood vessel to swell increasing the blood in the brain during an attack. CGRP also triggers inflammation throughout the brain.

Blocking the activity of CGRP has been shown to effectively suppress or interrupt migraine symptoms in at least 60% of patients in large clinical studies.

The CGRP blockers equal the efficacy of triptans but without the risks of vasoconstriction or other side effects.

What are monoclonal antibodies?

They are a medicine that harnesses a natural function of our immune system.  Our bodies manufacture different antibodies to identify and attach to very specific molecules on the surface of foreign bodies or certain cell membranes.  Monoclonal means that scientists have been able to create many exact duplicates of the same antibody. Currently, there are four pharmaceutical companies that have manufactured four distinct monoclonal antibodies.  Each targets either the neurotransmitter CGRP or the CGRP receptor on the nerve cell that transmits the pain signal to the brain.

Monoclonal antibodies go to work quickly and most people gain some relief within days of taking the medicine. It takes about 30 days for half of the monoclonal antibodies to become inactive.

Monoclonal antibodies are large molecules and they are too big to enter into the brain.

Who should use this medicine?

They have all been studied successfully for people with both episodic and chronic migraine. It works for all migraine types, including medication overuse headache. Patients should be 18 years or older.

How do I take this medication?

This new class of medication must be injected either subcutaneously or intravenously. After an initial administration under supervision and in the safety of a medical facility, patients can use the autoinjector at home. The antibodies can be injected subcutaneously in an arm, leg or the abdomen.

What are the risks of this medicine?

  • The most important features of monoclonal antibodies are that they are not associated with any drug interactions, allergic reactions, carcinogenesis or genetic interference and have minimal side effects.
  • The injection is relatively painless but there can be some burning. Constipation is one of the most common complaints. A stool softener may be helpful.
  • Monoclonal antibodies do cross the placenta and appear in breast milk.
  • It is not yet clear of what long-term effects of blocking CGRP in a developing fetus or child might be. Therefore, the current recommendation is that if a woman is planning a pregnancy, she stop monoclonal injections for 6 months.
  • If a woman has a pregnancy while taking this medication, the FDA has a pregnancy registry that will help to collect information about the risk of this medicine.

Can I take any of my other migraine medicine?

There are no known drug interactions. Patients who use monoclonal antibodies do not have to stop taking any of their current medications, including migraine interventional and preventive medications or other treatments.

What are the different monoclonal antibodies?

The four different monoclonal antibodies, erenumab, galcanezumab, fremanezumab and eptinezumab are in various stages of FDA approval and availability.

There are some minor differences. Erenumab uses a replicated human antibody while the other three antibodies are partially a mouse antibody but it is not clear that this will make any difference in how our bodies react to these drugs. Erenumab also is the only monoclonal antibody that attaches and blocks the CGRP receptor, or docking station. The other three attach to the CGRP protein itself.

Eptinezumab is the only one that is injected intravenously. A single intravenous dose of eptinezumab is given every 3 months.

How well do monoclonal antibodies work?

Erenumab: When given to prevent chronic migraine, erenumab resulted in an average of a 6.7 days reduction in monthly migraine days compared to where people started from, which would represent 79 fewer migraine days per year

Galcanezumab: Treatment with either 120 or 240 mg of galcanezumab significantly reduced monthly migraine headache days by 4.7 days compared with placebo (2.8 days). Since not everyone responds to monoclonal antibodies, for one out of three patients, galcanezumab (as well as eptinezumab) reduced monthly migraine days by at least 75%.

Fremanezumab: The reduction in the average number of headache days per month was 4.3 with fremanezumab quarterly vs. 2.5 with placebo. The percentage of patients with a reduction of at least 50% in the average number of headache days per month was 38% in the fremanezumab-quarterly group, 41% in the fremanezumab-monthly group, and 18% in the placebo group.

Eptinezumab: Almost 30% of patients receiving a 300 mg dose of the antibody had a 75% reduction in monthly migraine days from their baseline level of 8.6 days per month, compared to 16% of the placebo group.

It is good to know that the calculation of headache day reduction is an average of all study participants. Individual responses vary significantly. Some 10-15% of users have complete resolution of their headaches, while the majority had a 50% or more reduction in headaches but for others there was a mild or no therapeutic response. Nonetheless, these positive results were consistently better than placebo.

How much will monoclonal antibodies cost me?

Erenumab: Its cost is $575 per month, or $6,900 annually, less than botulinum toxin.

It is available to people with commercial insurance for any type of migraine. Your physician can write a prescription and provide information about different programs that will make the medicine available at your pharmacy with a copay of $0 or $5. Currently, Medicare does not cover erenumab; they are supposed to decide on coverage by November 17, 2018. Medicaid does not cover erenumab; no indication on when they will decide on coverage

Galcanezumab: This monthly auto-injector costs $575 per month.

There is a program offering people 12 months of this medication free of charge.

Click here to find CGRP Financial Assistance Guides for the current CGRP treatments from CHAMP

High Blood Pressure medicines

How it works

This beta-adrenergic blocking drug may suppress the central catecholaminergic system by inhibiting norepinephrine release, reducing neuronal activity and excitability, stabilizing cell membranes and inhibiting nitric oxide production. Altogether the effects make the brain less reactive.

Possible side effects

  • Fatigue
  • Depression
  • Low blood pressure (dizziness and lightheadedness, cold fingers and feet)
  • Sexual dysfunction (decreased libido and function)
  • Worsen asthma (limits use in young adults)
  • Vivid dreams and nightmares
  • Memory loss

Caution

It is extremely important not to stop the drug abruptly. Lower dose when combined with Rizatriptan (Maxalt). Some evidence suggests that people with migraines who have had a stroke should avoid beta-blockers.

Calcium channel blockers

Although not FDA-approved for migraine, several different agents including: Verapamil, Flunarizine (not available in the United States), Nimodipine, Nifedipine, Cyclandelate, and Nicardipine.

How it works

Calcium-channel blockers most likely act by suppressing nitric oxide. The drug decreases calcium influx, resulting in decreased activity of neural nitric oxide synthase and lower production of nitric oxide. Calcium-channel blockers can also suppress the neurovascular inflammation by inhibiting the release of vasoactive neuropeptide release and suppressing trigeminal nerve activation.

A current strategy in migraine prevention is the suppression of cortical spreading depression. Animal models show that prolonged treatment with Topiramate or Amitriptyline, as well as Beta-blockers, Valproate, or Methysergide, reduced the number of cortical spreading depressions.

For more detailed information on Verapamil’s mechanism of action see drugfx.com.

Possible side effects

The most common side effects are related to reducing the pumping mechanism of the heart:

  • Heart failure
  • Dizziness
  • Low blood pressure
  • Atrioventricular (AV) block
  • Change in heart rate
  • Shortness of breath
  • Fatigue
  • Nausea
  • Headache
  • Increased levels in liver enzymes
  • Constipation
  • Rash
  • Swelling
  • Flushing and fluid in the lungs

Avoid Verapamil if they have severe heart abnormalities, low blood pressure, poor heart function, certain heart rhythm problems, certain types of blockages in the heart called second or third degree Atrioventricular (AV) block, rapid heart rate or any allergic reaction to Verapamil.

Anti-seizure drugs

How it works

Anti-seizure drug appear to control migraine symptoms by targeting one or more sites in the brain – altering transmission of neurologic electrical signals through their effects on ion channels, neurotransmitter receptors, and neurotransmitter metabolism. Not all anti-epileptics have equal effectiveness.

Some examples are:

  • Divalproex sodium (Depakote)
  • Topiramate (Topamax)
  • Valproic acid (Depakene)/sodium valproate (Epilim)
  • Zonegran (zonisamide)

Possible side effects (vary by drug)

Mild side effects and will go away with continued use of the medicine

  • Tingling in the hands or feet is common but will pass with continued use of Topiramate
  • Change in taste, particularly with carbonated drinks
  • Nausea, vomiting, diarrhea, cramps
  • Fatigue and sleepiness
  • Hair loss
  • Dizziness
  • Blurred vision
  • Tremor
  • Weight gain
  • Topiramate can reduce the efficacy of the contraceptive pill

More serious side effects

  • Interference with mental function (highly dependent upon how quickly the dose is increased and is relatively uncommon among patients started at a low dose and advanced slowly.)
  • Stop use if slowing your activity or excess fatigue.
  • Weight loss (Topiramate): Some patients lose weight, as high as 15-20% of their body weight in his practice, and other patients do not lose any weight. Patients tend to come to a new weight and stabilize there. Higher doses generally result in more weight loss.

Serious side effects

Valproate and Divalproex can cause serious side effects of inflammation of the pancreas (pancreatitis) and damage to the liver. Monitor liver function and platelets.

Supplements and vitamins

How it works

Studies show that migraine sufferers have lower brain and blood levels of micronutrients (riboflavin, magnesium and coenzyme Q10) than nonmigraineurs (Hershey, 1999; Hershey, 2007; Mauskop, 1998).

A deficit of these nutrients could play a role in how well nerves can function. The common effect of these micronutrients on mitochondrial dysfunction may explain why they are ineffective for some people who likely do not suffer from this etiology of their migraine disease and only partially reduce symptoms in other people in this complex disease.

Magnesium: Needed in various biological processes that occur with migraine (vasoconstriction, platelet inhibition, secretion of serotonin). Magnesium is also needed as a co-factor for proper functioning of the ATP-synthase, which produces ATP. Furthermore, magnesium is the physiological antagonist at the NMDA-channel which is involved in the regulation of neuronal excitability.

Riboflavin: A precursor for flavin-mononucleotide (FMN) and flavin-adenine-dinucleotide (FAD). Both are essential components of complex I and complex II responsible for electron-transport in the mitochondrial membrane. Like CoQ10, it also works as an antioxidant by mopping up the damaging free radicals.

Memantine: May reduce migraine symptoms by blocking a glutamate receptor in the brain (glutamate N-methyl-D-aspartate receptor antagonist). Like serotonin, glutamate is a chemical that helps to send messages between nerve cells.

Melatonin: Linked to a variety of mechanisms related to the pathophysiology of headaches such as its anti-inflammatory effects, toxic free radical scavenging, reduction of pro-inflammatory cytokine up-regulation, inhibition of nitric oxide synthase activity and dopamine release, GABA and opioid analgesia potentiation, glutamate neurotoxicity protection, neurovascular regulation, and serotonin modulation. Melatonin’s chemical structure is also very similar to indomethacin, a common NSAID. (Peres, 2005)

Coenzyme Q10: A vitamin-like compound that can be synthesized by the body from phenylalanine and tyrosine. Coenzyme Q10 is needed for all cellular processes requiring energy. Coenzyme Q10 is an electron-carrier, transferring electrons from complex I/complex II to cytochrome C.

Feverfew: A study of 17 migraine patients, those on feverfew had half as many headaches. (Johnson, 1985) In a second study of 72 patients those who took feverfew had a 24% reduction in the mean number and severity of attacks although the duration of the individual attacks was unaltered. (Murphy, 1988)

Butterbur (Petasites hybridus:) 50 or 75 mg – This herbal remedy has been used for migraine and other uses for centuries. More recently, two studies (Diener, 2004; Lipton, 2002) demonstrated efficiency and safety of butterbur in adults. Another study (Lipton, 2004) showed that patients who used 75 mg butterbur twice daily for 4 months enjoyed 58% migraine attack reduction versus 28% in placebo group.

Possible side effects

Magnesium: Risk of side effect increases with higher doses. If any of these symptoms were to occur, a lower dose may still be well tolerated and effective.

  • Diarrhea (remember Milk of Magnesium)
  • Gastrointestinal discomfort
  • Constipation

Risk of side effect increases with higher doses. If any of these symptoms were to occur, a lower dose may still be well tolerated and effective.

  • Diarrhea (remember Milk of Magnesium)
  • Gastrointestinal discomfort
  • Constipation

Riboflavin: Minimal because the absorption of oral riboflavin is limited. At high doses it will produce:

  • A harmless yellow discoloration of urine
  • Itching
  • Numbness (insensitivity)
  • Burning/prickling sensations

Melatonin: Excess melatonin can cause

  • Headache
  • Short-term feelings of depression
  • Daytime sleepiness
  • Dizziness
  • Stomach cramps
  • Irritability
  • Hypothermia (reduced body temperature)
  • Stimulate overproduction of the hormone prolactin, which can cause hormonal problems and even kidney and liver issues in men

Coenzyme Q10

  • Nausea and/or vomiting
  • Diarrhea
  • Heartburn and stomach pain
  • Loss of appetite
  • Itching or rash
  • Insomnia
  • Dizziness

Feverfew

  • Increased heart rate
  • Mild stomach-ache
  • Mouth sores when chewing fresh feverfew leaves

Butterbur: The butterbur plant also contains liver-toxic pyrrolizidine alkaloids and potential cancer causing chemicals, which are removed by a special patented treatment and only marketed under the name Petadolex®. No part of the Petasites plant should be ingested other than the commercial products. The United Kingdom Medicines and Healthcare products Regulatory Agency (MHRA) announced in 2012 that Butterbur products are linked with liver toxicity and should be removed from the market.

Studies have reported safety and good tolerability of commercially available butterbur products that are free of potentially carcinogenic pyrrolizidine alkaloid constituents, when used short-term, orally and in recommended doses.​

Selective serotonin reuptake inhibitor (SSRI)

These medicines are also antidepressants, but they can act as pain relievers. Not usually as effective as amitriptyline or nortriptyline. There is very limited evidence to support the use of SNRIs in migraine.

Antidepressants take 3-10 days to be effective. Taper off this medication after 6 months.

Possible side effects

  • Slight increase in BP slightly
  • Problems with vision
  • Worse head pain
  • Drowsiness, dizziness, feeling nervous
  • Strange dreams
  • Increased sweating
  • Blurred vision
  • Dry mouth
  • Changes in appetite or weight
  • Mild nausea, constipation
  • Decreased sex drive, impotence, or difficulty having an orgasm

Download the Patient Brochure

Diagnostic questions, treatment options, dosages and preventative measures.

Interventional Treatments

When managing your triggers is not enough to control your symptoms, you may want to consider a medicine that will “calm down” your nervous system. They are designed to make subtle changes in how the nervous system transfers information and this can reduce the intensity, duration and frequency of pain and other unpleasant symptoms.

These recommendations are based on the strength of clinical trials studies and therefore you must understand that there are other medicines that may work but have not been studied thoroughly enough to be in the top two tiers of these guidelines.

In other words, these guidelines list those medications that have been best evaluated and showed the greatest promise that they might work.

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.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs, such as ibuprofen (Advil, Motrin) and naproxen (Aleve, Anaprox) can effectively control migraine pain in many conditions.

How they work

They suppress the pain and inflammatory phase of a migraine attack. Normally during migraine attacks, prostaglandins are released and they sensitize pain sensors. NSAIDs block the synthesis of prostaglandins.

NSAIDs block the enzyme cyclooxygenase (COX) from synthesizing prostaglandins, which cause pain and inflammation. NSAIDs may not only reduce pain transmissions through these nerves, but reduce the generation of further cortical spreading depressions.

 Medication details for Nonsteroidal Anti-inflammatory Drugs:

Excedrin Migraine

(Acetaminophen 250 mg, aspirin 250 mg, caffeine 65 mg)

Many migraineurs find this OTC medication effective for their occasional headaches and other migraine-related symptoms.

Possible side effects

  • GI bleed
  • Migraine is not relieved or worsens after first dose
  • Tinnitus
  • Loss of hearing
  • New or unexpected symptoms develop

Fioricet

Acetaminophen (Tylenol), butalbital, and caffeine)

How it works

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.

Possible side effects

Get emergency medical help if you have any of these signs of an allergic reaction:

  • hives
  • difficulty breathing
  • swelling of your face, lips, tongue, or throat

In rare cases, Acetaminophen may cause a severe skin reaction that can be fatal. This could occur even if you have taken acetaminophen in the past and had no reaction. Stop taking this medicine and call your doctor right away if you have skin redness or a rash that spreads and causes blistering and peeling. If you have this type of reaction, you should never again take any medicine that contains acetaminophen.

Stop using Fioricet and call your doctor at once if you have:

  • Confusionn or seizure (convulsions)
  • Shortness of breath
  • A light-headed feeling or feeling like you might pass out
  • Nausea
  • Upper stomach pain
  • Itching
  • Loss of appetite
  • Dark urine
  • Clay-colored stools
  • Jaundice (yellowing of the skin or eyes)

Common Fioricet side effects include:

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

Triptans

How it works

There are about 14 different serotonin “hydroxytryptamine” or HT receptors in our nervous system. They control how signals are sent throughout the nervous system.

The seven triptans—almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan—block and stimulate the neurotransmitter serotonin receptor 5HT1B/1D. Stimulating this receptor leads to constriction of the brain’s blood vessels and reduce the throbbing head pain. Like ergots, they dampen inflammation. But 5-HT receptor stimulation also may block neural signaling and suppress neural activity and central sensitization.

Possible side effects

Triptans may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be alert.

Serotonin Symptom – A dangerous but rare condition caused by excessive release of the neurotransmitter serotonin. The concern is whether a person on an antidepressant, such as amitriptyline (Elavil), can safely take a triptan, such as sumatriptan (Imitrex), because they both cause increased release of serotonin.

Symptoms of serotonin syndrome:

  • Confusion
  • Agitation
  • Blood pressure changes
  • Body temperature changes: shivering and sweating
  • Rapid pulse
  • Muscle twitches: coordination
  • Gastrointestinal symptoms including nausea, vomiting and diarrhea

Sumatriptan

How it works

This triptan is available as a generic triptan.  It is an inexpensive and effective treatment for occasional intense headaches and other migraine symptoms.  Studies have found that it is as effective as or better than most of the other triptans. But, like all triptans, it is also not safe for children, patients with heart and circulatory problems and pregnant women.

Dosing

At the onset of symptoms, take one dose of sumatriptan with fluids.   Repeat dose at intervals of at least 2 hours is an option, but do not take more than 200 mg/day.

For people with liver disease, do not take more than 50 mg at a time.

People are limited to 9 tablets per month because more frequent use of any triptan can raise the risk of rebound headaches.

For adults 25, 50 or 100 mg tablets are available.  Sumatriptan is also available as a nasal spray, skin patch (Zecuity) and auto-injection kits. 1st dose should be supervised. Prescriber should instruct the use of autoinjector.

If sumatriptan doesn’t work for you, we recommend trying rizatriptan (Maxalt and generic). Studies indicate it works very well in delivering pain relief within two hours compared with many of the other triptans. But it may be more expensive.

Warnings

Sumatriptan can stress the heart and liver and can bring on a stroke.  Do not use sumatriptan if you have a history or symptoms of uncontrolled high blood pressure, heart disease, stroke, TIA or angina, ischemic bowel disease or poor circulation.

People who are at risk of coronary artery disease (e.g., postmenopausal women, hypercholesterolemia, men over age 40, hypertension, obesity, diabetes, smokers, strong family history) may be a candidate for a screening ECG and long-term users of sumatriptan should be monitored for heart disease.

Sumatriptan is not recommended for older people or pregnant women.  Register pregnant patients exposed to sumatriptan by calling (800) 336-2176.  Nursing mothers should avoid nursing for 12 hours after treatment.

It is rare but there can be serious cardiac and cerebrovascular events (including fatalities), vision loss. The nasal spray can cause odd smells,

Other Therapies

Cold Therapy (Cyrotherapy)

How it works

Lower temperature applied to the skin reduces pain by temporarily inactivating pain sensors in the skin and muscles. It may also reduce muscle tension.

Possible side effects

  • Freezing the skin
  • Reduced blood flow to the heart and rest of the body

Nerve Blocks

Trigger Point Injections

Trigger points are focal areas of muscle spasm, often located in the upper back and shoulder areas. 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 given in a doctor’s office and usually take just a few minutes. Several sites may be injected in one visit.

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

Greater Occipital Nerve (GON) block

Neurologists working in the headache field used GON local anesthetic (lidocaine, bupivacaine, clonidine, and fentanyl) or steroid injections into region of the sensory nerves at the back of the neck (the greater occipital nerve and lesser occipital nerves). The exact composition of the nerve block can vary between physicians.

The goal is to provide pain relief for up to 2 months in chronic migraine sufferers. In a recent study the GON block did not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo*.

The efficacy and use of GON blockade in primary headache other than migraine, for example, cluster headache and cervicogenic headaches (unilateral neck pain and stiffness), is already better established.

* Dilli E, Halker R, Vargas B, Hentz J, Radam T, Rogers R, Dodick D. Occipital nerve block for the short-term preventive treatment of migraine: A randomized, double-blinded, placebo-controlled study. Cephalalgia. 2015 Oct;35(11):959-68.

The Placebo Effect

The popular video “How to get rid of headache or migraine in 2 minutes or less” by Kamil in which he asks the headache sufferer to answer three questions:

  • Where is your headache?
  • What shape is it? and
  • What color is it?

When this technique is effective in reducing or eliminating a headache, it may be taking advantage of the placebo effect. The placebo effect should not be thought of in the pejorative framework of “wishful thinking”, it is a real and powerful capability of our own nervous system to make us feel better.

For years the placebo effect has been the confounding factor for scientists in testing many of their ideas. It has been shown in many studies that just believing that something might help is enough to make it happen. Many believe that this explains the effectiveness of several alternative medical therapies, such as acupuncture. One scientist reported that 120 of 199 headache subjects that received a placebo obtained relief. In general, the placebo effect can be effective in roughly 30% of the time. But this is not necessarily a bad thing.

The placebo effect is most likely the result of harnessing our nervous system’s capacity to release its own opioid-like chemicals from deep in our brains (specifically the pituitary gland and hypothalamus). Researchers at the University of Michigan first documented the release of endogenous morphine neurotransmitters, better known as “endorphins”, within the brain on positron emission tomograms (PET scans) in 2005.

It is because of this confounding factor that most scientists will be doubtful of successful treatment reports that do not use a double-blinded, placebo-controlled clinical trial.  I should mention that the term “double-blinded” takes into account the unconscious bias that any person brings to a study in which neither the participants nor the experimenters know who is receiving a particular treatment.

This is really just a new variation on known techniques for controlling headaches. This technique of asking repeated simple questions bears some resemblance to meditating. Meditation is known to unlock our endorphins by calming the mind through simple repetition of a phrase. In fact, any number of relaxation techniques is known to reduce migraine headache frequency and intensity. And athletes know that their exercise is another way to release endorphins. Therefore, it is not surprising that exercise is known to relieve migraine headaches for some people.

Perhaps this video will open people’s minds to the option of cognitive behavioral therapy. Cognitive behavioral therapy (CBT) is a personal exploration of an individual’s thinking and ingrained reactions to a problem with a professional psychotherapist. The goal is to change the way that a person deals with their symptoms. For certain types of pain conditions, including migraine, it can be very effective, usually best when combined with another preventive therapy.

Cognitive-behavioral therapy (CBT)

Cognitive-behavioral therapy (CBT) is a psychological approach to managing headaches and migraine. The reason that people with headaches and migraine see a psychologist is not because those conditions are lacking a physical basis and it is all in their imaginations. Psychologists are involved in the treatment of pain for 2 reasons: 1) There are effective treatments for migraine and headache (e.g., relaxation strategies, stress management and coping strategies, assertive communication) that psychologists have been trained to administer, and 2) Patients suffering from chronic headaches and migraine may also be in a vicious cycle which is often helpful to discuss with someone familiar with them, i.e. pain causes stress, tension, anxiety, and/or depression which also causes more pain.

CBT assists in the reduction of the vicious cycle by facilitating the development of skills that increase your ability to cope with pain and reduce headache-related psychological distress. CBT is an intervention based on scientific evidence that uses various cognitive and behavioral strategies. A study of outpatient combined group and individual cognitive-behavioral treatment for adult patients with migraine and tension-type headache found a significant reduction in average headache intensity, headache frequency, and unhelpful thoughts about headache as well as an increase in the use of adaptive coping strategies. A review of the existing research showed that cognitive-behavioral therapy and relaxation techniques lead to a significant reduction in headache activity ranging from 30% to 60%.

Cognitive-based interventions are based on the assumption that much of what we feel is determined by what we think. Cognitive strategies focus on identifying and challenging unhelpful thoughts and responses to stressful events. They aim to enhance headache sufferers’ ability to engage in behaviors that enhance their self-management of headaches. Reductions in negative thoughts about headache pain and the use of a greater number of positive coping strategies were associated with reductions in the disabling effects of headache in a research study comparing behavioral migraine management training, use of beta blocker medications, and a placebo.

Increasing and/or fine-tuning your coping skills can also positively impact your headache experiences. CBT also includes learning how to recognize and cope with headache triggers. Treatment also typically includes:

Improving Wellness Activities

  • These include strategies to improve: Sleep, Physical Activity, Hydration, and Eating Habits.
  • Inconsistent and/or poor habits in these areas contribute to headaches and often involve small changes that reap large benefits.

Relaxation Strategies

  • These reduce the arousal of the central nervous system and reduce muscle tension which both are implicated in headaches.   In addition, you are absorbed in a pleasant state which is incompatible with pain.
  • Effective relaxation strategies include: Progressive Muscle Relaxation, Visual Imagery, Autogenic Relaxation, and Meditation.

Stress Management Techniques

  • Stress can precipitate individual headache episodes, exacerbate the progression of headaches, worsen the headache sufferer’s quality of life, and be a result of frequent headaches.
  • Stress management techniques include the altering or adapting to stress triggers, getting support for undertaking tasks, problem-solving skills, and assertive communication as well as the previously mentioned relaxation strategies.

Managing Headache Triggers

  • Light/glare, weather, smells/odors, dust, and alcohol can be headache triggers.
  • While many individuals have developed some strategies to manage these triggers, often fine-tuning strategies can be valuable.

Pacing of Activities

  • Headache sufferers get concerned about how headaches impede their productivity or functioning at work, home, or in social situations. In an effort to make up for lost time, when pain is tolerable they overexert themselves and usually increase their pain.
  • Pacing is based on observing what activities increase pain after what period of time and an awareness of one’s limits. The objective is for the patient to be able to alternate active times with sedentary times and thereby get more accomplished without increasing pain and fatigue.

The chief goal of CBT is to exchange sick time for wellness time. You can spend the exchanged time enjoying yourself, staying healthy, managing triggers and stress thereby minimizing headaches

Cannabis

What is 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 can be used for nausea, pain relief, insomnia and as an appetite stimulant. CBD can decrease pain, inflammation and anxiety without a psychoactive effect. It is believed that CBD and THC are more effective when consumed together. 

How to Consume Cannabis?

The quickest onset of consumption is inhalation by smoking or vaping. 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 recommended to start CBD at a low dose around 5 mg per day and slowly increase 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 health care provider prior to starting a new treatment or changing dosages. 

POSSIBLE SIDE EFFECTS

CBD must be used in caution with drugs that induce the liver enzymes CYP3A4 or 2C19 such as anticoagulants, antiepileptics, 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 potential 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. For more information on cannabis and migraine visit Migraine Buds.