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Treatments

Migraine is a disease that lacks a specific diagnostic test and it is without a cure. It is a chronic condition that needs to be managed

If you suffer from either migraine headaches or other migraine disorders, there can be relief.

There are two different approaches;

1. treating the symptoms when they occur (acute intervention) or

2. preventive medications where daily medicines are taken to reduce the intensity or frequency of symptoms (preventive or prophylactic medications).

Although it is not officially endorsed, the use of a preventive medicine can be helpful to confirm a suspected diagnosis.

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

Preventative Treatments

Expect trying more than one agent

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.

Preventive Medication Details

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

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.

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.

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.

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.​

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

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.

If you have:

Mild or infrequent symptoms

Start with over-the-counter (non-prescription) pain relievers

  • Acetaminophen (Tylenol and generics)
  • Non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil and generics), or naproxen (Aleve and generics)
  • Combination products that contain acetaminophen, aspirin, and caffeine (Excedrin Extra Strength, Excedrin Migraine, and generics)

View the dosage information for mild or infrequent symptoms.

Moderate symptoms

  • Acetaminophen/Aspirin/Caffeine combination
  • Triptan
  • Ergot medicine such as dihydroergotamine (D.H.E. 45, Migranal), ergotamine (Ergomar, Cafergot, Migergot), dihydroergotamine (D.H.E. 45, Migranal), or methylergonovine (Methergine)
  • Acetaminophen / Isometheptene / Dichloralphenazone

View the dosage information for moderate symptoms.

Severe in pain intensity, and/or disrupt your life

  • Triptan, plus pain reliever
  • Triptan, plus anti-nausea medication (if nauseated)
  • Barbiturates
  • Intravenous medicines (available in emergency department or hospital)

View the dosage information for severe symptoms.

Do not use any of these medicines more than 15 days per month for three months.

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.

 

View medication details for Nonsteroidal Anti-inflammatory Drugs:

(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

(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)

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

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

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

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 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) 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.

Learn more about current treatments from our podcast guests

The New CGRP Blocking Migraine Treatments

Neurologist Dr. Stewart Tepper explains how the new, “designer” CGRP blocking migraine treatments work, how they are delivered and what to expect for efficacy. These medications come in two different types – gepants and monoclonal antibodies.

Cannabis for Treating Migraine and Cluster Diseases

Dr. Shivang Joshi of the Dent Neurologic Institute gives a presentation on the use of Marijuana or Cannabis for treating migraine and cluster diseases. He touches on a bit of the pharmacology, the history of its use, adverse effects, who uses it, what studies have shown, and legal implications, dosing and more.