Most migraine treatment plans involve both acute and preventive strategies (Braun 2010).
The goal of acute or abortive treatment is to relieve the intensity and/or duration of an imminent or ongoing migraine as quickly as possible (Hershey 2011).
First tier options for acute migraine management may include non-steroidal anti-inflammatory drugs (NSAIDs) and/or mild analgesics (e.g., acetaminophen or aspirin) (Hershey 2011; Bajwa 2012). Caffeine, due to its vasocontrictive properties, is sometimes combined with aspirin and/or acetaminophen as well (Aukerman 2002). However, these options may not be sufficient for treating severe migraines, in which case a variety of drugs in the triptan class may be considered (Hershey 2011).
The triptan drugs (e.g., sumatriptan, rizatriptan, eletriptan, and almotriptan) act on several specific mechanisms of a migraine headache, such as promoting vasoconstriction and blocking pain pathways in the brainstem. Triptans mediate these effects by activating certain serotonin receptors in cranial blood vessels (Bajwa 2012).
Although the triptans are arguably the most effective treatment for acute relief of a migraine headache (i.e., the "gold standard"), they have a number of side effects (Cady 2011). For example, triptans should be avoided (when possible) in patients who are at risk for cardiovascular events and stroke (i.e., patients with heart disease). Furthermore, triptans require careful monitoring because they are known to interact with a large number of other commonly used medications (Bajwa 2012).
Other drugs that may be used to treat migraine include ergot alkaloids, which cause blood vessel constriction, opioids, and, less commonly, corticosteroids(MD Consult 2011).
Medicating as early as possible during migraine increases the chances of successfully aborting an attack or reducing its intensity (Aukerman 2002).
The main goals of preventive therapy are to reduce migraine frequency, severity, and duration, as well as improve responsiveness to acute treatment(s). Preventive treatment options include headache trigger avoidance, daily medication, physical therapy, and/or behavioral therapy (Braun 2010).
Drugs used to prevent migraines include blood pressure medications (e.g., beta blockers, calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers), tricyclic antidepressants (e.g., amitriptyline [Elavil®]), and anticonvulsants (e.g., valproate [Depakote®], gabapentin [Neurontin®], and topiramate [Topamax®]). These drugs should be started at low doses, and given adequate time to reach peak effectiveness. Therefore, depending upon the chosen medication, a proper drug trial could take anywhere from four weeks to three months to take effect (Bajwa 2010).
Ironically, taking too much migraine prevention medication for too long can lead to "medication overuse headache". Medication overuse headache can become a chronic, self-perpetuating condition called "chronic daily headache", in which patients experience daily headaches caused by medication overuse, but continue to use medication to relive the headaches. To prevent medication overuse headache, migraine patients should (on average) limit use of NSAIDs to 15 or fewer days a month and limit triptan or over-the-counter combination analgesic use to 9 or fewer days a month (Garza 2012; Young 2001).
Although there are a wide variety of acute and preventive drugs available for treating migraines, many patients will not experience significant symptom relief unless healthy lifestyle modifications are made (Sun-Edelstein 2009a). The following lifestyle interventions may prevent migraines (Chaibi 2011b; Gallagher 2012; Linde 2009; Honaker 2008, Hauge 2011 ):
- avoidance of caffeine, nicotine, red wine, and other migraine triggers
- stress reduction (see the Stress Management protocol)
- improving sleep hygiene (see the Insomnia protocol)
- massage therapy
- chiropractic manipulation
- getting sufficient exercise
- and frequent stretching