Wednesday, May 29, 2013

How to treat Migraine


I. Migraine

Migraine is a chronic neurological disorder characterized by recurrent attacks of moderate to severe headache. A migraine headache has a throbbing or pulsating pain, usually on only one side of the head or unilateral lasting from 2 to 72 hours. Symptoms that are associated with this kind of headache are nausea, vomiting, and extreme sensitivity to light (photophobia) and sound (phonophobia). Migraine headaches, which are often misdiagnosed as sinus or tension headaches, are severe enough to interfere with sleep, work, and other everyday activities. They may occur as often as several times per week or as rarely as once or twice a year.

Most people with migraine headaches perceive a transient visual, sensory, language, or motor disturbance which signals that the headache will soon occur which is called an aura, but sometimes they feel the aura but won't have a migraine. 

Approximately 30 million people in the US are suffering from migraine. Though it can affect teens and kids, it is most common among people with the age range of 25 to 55. Women are more prevalent to have migraine than men.

II. Classification or Types of Migraine

Common Migraine:

It is called a migraine without aura. It is the most widespread type of migraine. Fatigue, anxiety, mood changes, and mental fuzziness are among the symptoms frequently experienced.

Classic Migraine:

Called migraine with aura, it occurs in about one-fifth of migraine sufferers. Visual or other sensory symptoms called auras most often occur before a headache but can also appear during or after a headache. Most commonly, sufferers see auras that are flashing lights, zigzag lines, or blind spots. Auras can also include feelings of numbness or tingling, speaking difficulty, world spinning, ringing in the ears, smelling a strange odor, having an odd taste in the mouth, or a number of other brainstem-related symptoms, but not motor weakness.

Menstrual Migraine:

This type of migraine is related to fluctuating levels in estrogen during a woman's menstrual cycle. 60 to 70 percent of female migraine sufferers report a relationship between their migraine headaches and menstruation.

Abdominal Migraine:

Abdominal migraine is an episode of moderate to severe abdominal pain, nausea, or vomiting that can last up to 72 hours. It is typically seen in children, especially those with a family history of migraine. Children who suffer from abdominal migraines usually suffer from classic migraine headaches as adults.

Retinal Migraine:

Also known as ocular migraine, involves migraine headaches accompanied by visual disturbances or even temporary blindness in one eye that can last an hour or less and is not always accompanied by headache.

Familial Hemiplegic Migraine:

A rare inherited condition caused by one of several chromosomes. In hemiplegic migraine, one side of the body may have some accompanying temporary motor weakness or body may go numb during a migraine headache.

Basilar Artery Migraine:

a type of migraine that causes a headache, usually in the back of the head, and is associated with an aura that includes dizziness, confusion, problems speaking, hearing changes, and visual disturbances. It is usually related to hormonal changes and most often affects young adults.

Ophthalmoplegic Migraine:

This is a rare type of migraine that requires emergency treatment. Patients develop a partial or complete paralysis in nerves required for eye movement.

Status Migrainosus:

A rare condition characterized by an extremely severe headache that lasts longer than 72 hours. Hospitalization is often required to relieve symptoms.  

Chronic or Transformed Migraine:

This is a form of chronic daily headache. Chronic migraine occurs when, over time, a migraine becomes a continuous background headache with, occasionally, severe migraine symptoms. Sometimes called coexisting migraine and tension-type headache, it is challenging to treat.

III. Migraine Medication

There are two categories of drugs used to treat migraine. Acute treatment is for pain and other symptoms during a migraine headache. Preventive treatment is to reduce the frequency and severity of headaches. Preventive migraine medications are considered effective if they reduce the frequency or severity of the migraine attacks by at least 50%.

a. Acute Treatments:

While a migraine headache is in progress, ending it or reducing pain and other symptoms is of primary importance.


There are three main classes of drugs used to treat migraine headaches as they happen:

  • Non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics reduce pain and inflammation and may help relieve mild migraines. Most are available in both over-the-counter and prescription dosages.
  • Ergotamines cause blood vessels to constrict and relieve migraine symptoms rapidly.
  • Triptans have several different effects on the brain and its blood vessels and can stop a severe migraine headache very rapidly in many cases.

Often times these drugs contains caffeine to make them work quickly and effectively. People with migraine may be prescribed anti-nausea drugs to reduce the nausea and vomiting associated with migraine headaches. Opioid painkillers may be prescribed if other pain relievers stop working.

Hot or Cold Compress - Applying a hot or cold compress to the head or neck can reduce the severity of pain during a migraine headache.

Darkness and Quiet - Migraine headaches usually include sensitivity to light and sound. Therefore, sitting or lying down in a dark, quiet room can make a headache more bearable.

Drugs for Acute Treatment:

These drugs are taken at the onset of migraine symptoms or auras and have been proven to stop or reduce the severity of a headache. Taking any of these drugs too often can lead to medication-overuse headaches. If you need to use the acute migraine drugs more than nine times per month, consult your doctor to consider preventive treatments.

Painkillers - These kind of drugs reduce the pain of a migraine headache but will not stop one from occurring. Over-the-counter formulations are commonly used for migraine, but many of these drugs are also available in prescription-only strengths. Aside from acetaminophen, an analgesic drug that only relieves pain, the drugs on the following list are all non-steroidal anti-inflammatory drugs (NSAIDs), which relieve pain and reduce inflammation.

  • acetaminophen (Excedrin, Tylenol)
  • aspirin
  • diclofenac (Cataflam)
  • ibuprofen (Advil, Motrin)
  • ketorolac (Toradol)
  • naproxen (Aleve)

Many over-the-counter products marketed specifically for migraine or headaches in general combine one or more of the drugs above with a small amount of caffeine, which can make them work more quickly and effectively, especially for mild migraine headaches.

Possible side effects of long-term NSAIDs use include heart attack, stroke, kidney damage, and stomach ulcers.

Ergotamines - Ergotamines were the first class of drugs used specifically for migraine. They cause blood vessels around the brain to contract and can stop a migraine headache within a few minutes. Ergotamines are available as traditional swallowed pills, tablets that dissolve under the tongue, nasal sprays, suppositories, and injections. They are generally taken at the first sign of headache symptoms, and some delivery methods have the option to take additional doses every 30 minutes if the headache continues.

  • dihydroergotamine (DHE-45, Migranal)
  • ergotamine (Ergomar)
  • ergotamine and caffeine (Cafatine, Cafergot, Cafetrate, Ercaf, Migergot, Wigraine)
  • methysergide (Sansert)
  • methylergonovine (Methergine)

Ergotamines have a number of potentially dangerous side effects. They can cause birth defects and heart problems and are toxic in high doses. If you are pregnant or breastfeeding or have heart disease, you should not take ergotamines. Ergotamines can also interact negatively with other drugs, including antifungal and antibiotic medications.

Triptans - Triptans are a newer class of drugs that increase levels of serotonin in the brain. This reduces inflammation and constricts blood vessels, effectively ending a migraine headache. Triptans are available as traditional swallowed pills, nasal sprays, injections, and tablets that dissolve under the tongue. They work very quickly to stop migraine symptoms.

  • almotriptan (Axert)
  • eletriptan (Relpax)
  • frovatriptan (Frova)
  • naratriptan (Amerge)
  • rizatriptan (Maxalt, Maxalt-MLT)
  • sumatriptan (Imitrex)
  • sumatriptan and naproxen (Treximet)
  • zolmitriptan (Zomig)

Possible side effects of triptans include tingling or numbness in the toes, drowsiness, dizziness, nausea, and tightness or discomfort in the chest or throat. People with heart problems or serious stroke risk should avoid triptans. Triptans can also cause serotonin syndrome —a potentially fatal complication—if taken with another drug that increases serotonin, such as many antidepressants.

Antinausea Drugs - These drugs reduce the nausea and vomiting that can accompany migraine headaches. They are usually taken along with a painkiller as they do not reduce pain.

  • dimenhydrinate (Gravol)
  • domperidone (Motilium)
  • metoclopramide (Reglan)
  • prochlorperazine (Compazine)
  • promethazine (Phenergan)
  • trimethobenzamide (Tigan)

These drugs may make you drowsy, less alert, or dizzy and have other possible side effects. 

Opioids - If migraine pain does not respond to other painkillers and a patient cannot take ergotamines or triptans, a doctor may prescribe opioids, much more powerful painkillers. There are also many drugs that combine an opioid with one of the painkillers listed above.

  • codeine
  • meperidine (Demerol)
  • morphine
  • oxycodone (OxyContin)

Opioids carry a serious risk of addiction, so they are usually prescribed sparingly.

b. Preventive Treatments:

Lifestyle Changes – If you have a migraine, you need to figure out your personal triggers. Try to avoid them as much as possible to prevent headaches. There are many ways to do this:

Try to stay on a regular sleep schedule. Go to bed and wake up around the same time every day, even on weekends. Also make sure to get at least 8 hours of sleep.

Eat regularly. Missed meals and low blood sugar are migraine triggers.

Drink plenty of water. Dehydration can cause migraine headaches.

Avoid Food Triggers

These vary from person to person, but common ones include:

  • monosodium glutamate (MSG), found in many Asian dishes
  • nitrates and nitrites, found in processed or cured meats
  • sulfites, found in many dried fruits
  • aged cheeses
  • alcohol, especially red wine
  • chocolate
  • large amounts of caffeine

Exercise Regularly - During a migraine headache, exercise worsens pain, but otherwise, light to moderate exercise can relieve stress, another major migraine trigger.

Avoid Stressful Situations - If you feel stress building, try to remove yourself from the setting and calm down.

Limit Estrogen-Containing Medications - The hormones in birth control pills as well as in hormone replacement therapy drugs used for menopause symptoms can cause migraine headaches. If you're taking one of these medications and experience migraines, your doctor may consider reducing your dose or stopping the medication altogether.

Stress Reduction - There are various techniques available to reduce tension and stress. Studies have shown the following to be effective in preventing migraine headaches.

Biofeedback - This system teaches people to monitor and control their physical responses, including muscle tension and even blood pressure. Biofeedback was once considered an alternative treatment, but many studies have proven its effectiveness, and it is now a common migraine treatment.

Relaxation Therapy - There are various techniques used to relax the body, including deep breathing, visualization, and progressive muscle relaxation (a technique of tensing and relaxing various muscles in a specific order).

Cognitive Behavioral Therapy (CBT) - CBT is a form of psychological treatment that teaches patients to recognize and cope with sources of stress in their lives.

Massage - This can reduce muscle tension, encourage relaxation, and improve sleep.

Drugs for Preventive Treatment:

If migraine headaches are happening frequently, your doctor may prescribe a preventive drug to reduce the frequency and intensity of headaches. These drugs are taken on a regular basis, usually daily, and may be prescribed alone or in combination. It may take several weeks or months before effects are experienced. Preventive drugs for migraine are all most commonly used for other conditions but have been found to be effective for migraine as well.

Beta Blockers - Commonly prescribed for high blood pressure, beta blockers decrease the effects of stress hormones on the heart and blood vessels. They can help reduce both frequency and intensity of migraine headaches.

  • atenolol (Tenormin)
  • metoprolol (Toprol XL)
  • nadolol (Corgard)
  • propranolol (Inderal)
  • timolol (Blocadren)

Side effects of beta blockers include fatigue, nausea, dizziness when standing, depression, and insomnia.

Calcium Channel Blockers - Calcium channel blockers are blood pressure drugs that moderate the constriction and dilation of blood vessels; something believed to play a role in migraine pain.

  • diltiazem (Cardizem, Cartia XT, Dilacor, Tiazac)
  • nimodipine (Nimotop)
  • verapamil (Calan, Covera, Isoptin, Verelan)

Side effects of calcium channel blockers include low blood pressure, weight gain, dizziness, and constipation.

Antidepressants - Antidepressants affect levels of various brain chemicals, including serotonin.

  • amitriptyline (Elavil, Endep)
  • fluoxetine (Prozac, Sarafem)
  • imipramine (Tofranil)
  • nortriptyline (Aventyl, Pamelor)
  • paroxetine (Paxil, Pexeva)
  • sertraline (Zoloft)
  • venlafaxine (Effexor)

Side effects of antidepressants include weight gain and decreased libido.

Anticonvulsants - Anticonvulsants prevent seizures caused by epilepsy or other conditions. They work for migraine by calming overactive nerves in the brain.

  • divalproex sodium (Depakote, Depakote ER)
  • gabapentin (Neurontin)
  • levetiracetam (Keppra)
  • pregabalin (Lyrica)
  • tiagabine (Gabitril)
  • topiramate (Topamax)
  • valproate (Depakene)
  • zonisamide (Zonegran)

Side effects of anticonvulsants include nausea, vomiting, diarrhea, weight gain, sleepiness, dizziness, and blurred vision.

Botulinum Toxin Type A (Botox) - Botulinum toxin type A (Botox) injections in muscles of the forehead or neck can be helpful for some people with chronic migraine when other treatments fail. Generally they are repeated every three months so they can be costly.


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