Migraine Management – Medications & Treatments

Preventing  Migraines is a mine field – one fact remains, there is no cure only Migraine Management and if you get your management plan right then no more migraines.

There are, however, three key issues to bear in mind when you think about ‘treatment’.

  1. The doctors do not yet agree on what the cause of Migraine is – research is ongoing and there are a number of opinions – I am sure one day this question will get answered. (For example faults in Genes have recently been identified for some migraine types)
  2. There is no preventative treatment created purely for Migraine – every medication used for prevention was created for something else and found by accident to help with migraine.
  3. There is only one type of abortive medication created purely for Migraine.

So, the results of these every migrainer is different and reacts to the potential medication differently…. one shoe does not fit all and finding your personal management plan can take time….  a long time.

Then you have to look at the amount of attacks you are having, those whom are not chronic, will no doubt get away with OTC pain relief or an Abortive (Known as Triptans – see below)  since your attacks are far and few between and if you can work out your triggers, then your management should be straight forward…. but one thing is for sure if you have reached chronic levels (15+ days a month[1]) – you are going to have to make some life style changes……… as just popping a pill is not going to do it.

First let me clarify:

An ‘abortive’ is a medication which aims to stop an attack which has started – these are known as Triptans and there are seven types in the UK (see below)

‘preventative’ is a medication which aims to stop an attack before it starts. There are many of these (see below).

In all cases these need to be worked out with the help of a doctor. They all have potential side effects. So you need a doctor to work through a plan with you.  If you are non chronic then your GP will be able to help – if you are having more 15 headache days per month over a 3 month period of which more than 8 are migrainous, in the absence of medication over use you are chronic…. and you need the help of a Migraine or Headache Neurologist………. not all neurologists are the same and they tend to specialise – you need one who works in a headache clinic…. again your GP will refer you.

Please note that less than 1%  of the population have chronic migraine, but this still means that there over 610,000 chronic migraine sufferers in the UK.

Self help

Unlike a lot of illnesses Migraine is one which has a certain degree of self help – I know it’s a cruel illness and when you are at your worse you just want someone to take it away… but you know your body better than anyone else. And those who take a certain degree of control seem to come out better – popping a pill and hoping it goes away is not going to work here.

Chronic Migraine Management needs to be tackled on many levels:

Medication:  Yes you will need a preventative medication and you will need your doctor’s help here – a brief over view is below. Have patience with this if you are chronic – there are some people that hit on the right medication first time, however, there are those who take who take a while to find the right one or combination – some take a while to build in your system so again patience is needed – the trick here is not to give up and stay positive.

Trigger avoidance: Migraines are triggered – if you can work out your triggers and avoid as many as possible, things will improve. This can mean some major life style changes. Keeping a Migraine Diary can help here as at first you may not notice the small changes  caused by avoiding something.

Routine: Migraines seem to happen less if you have a routine.  So follow the basics and listen to your body – drink, eat, sleep – all have to be done regular.  Missed meals, dehydration, lack or even too much sleep can all trigger an attack.

Complimentary Therapies: Look in to relaxation techniques – I am going to stick my neck out here – but I am not sure that some of the complementary techniques themselves are what is working – but the fact that whilst you do them you are relaxing…. It really does not matter –  and for some people these work wonders and should not be underestimated. Things like Reflexology, Acupuncture, Massage, Beuyko Breathing, Meditation, Yoga – anything which brings you inner peace and relaxation. (One theory is that migraine is caused by over stimuli of the senses and thus the nervous system so anything which helps you relax should help)

Vitamins and Mineral:  There are been some studies that show that some of these can help with the reduction of attacks in some people, again everyone is different, but these should not be ruled out – things like Butterbur, Feverfew, Magnesium,  Vit D, 5 HTP, Q10, B12 can help.

Find Peer Groups & Support: Do your homework and talk to a peer group – there are many who have walked this path before and you will find other peoples experiences, insight and their stories may resonate with you and stimulate you to try something different.  Also the support you get from those people who understand cannot be underestimated – having chronic migraine can be a lonely long road to travel – even close family and friends get tired of hearing about it and supporting – but you are not alone – and gaining peer support can do wonders – even if just providing you with a place to vent your feelings and get a virtual hug. There are also some very good charities both in the UK and USA who provide free information and support services.

Listen and say NO: One of the best ways to manage migraine is to listen to your body and learn to stop.  Over time you will begin to recognise the signs. Most Migraines build (See potential stages) and if you can spot the signs early and act then you may lessen the impact.  But you have to let yourself say NO……. the guilt of running around and having ‘normal’ life has to be let go  – you have to learn that it is OK to say NO. On a personal note I know that if I overdo things I trigger – so if I have something planned I will make sure I am not doing anything a few days before and that I have a rest day after – over time I have worked out that if I plan rest before and after I can normally make the event – not to say I will stay the course – but I should be able to at least get there.

Abortive Medication – Tripans

These were developed to treat migraine, they control the serotonin imbalance. They are taken at the first signs of a migraine in the hope to stop one developing

There are seven types of triptans in the UK:

  • Almotriptan (Almogran)
  • Eletriptan (Relpax)
  • Frovatriptan (Migard)
  • Naratritan (Naramig)
  • Rizatriptan (Maxalt)
  • Sumatriptan (Imigran)
  • Zolmitriptan (Zomig)

Imigran is the only over the counter one – but you will still need to fill a complex form to get it –  all the others are only available on prescription from your doctor. They are not for everyone. And I would strongly recommend you talk to your doctor before you take these.

(You may find other brand names appearing as some of the licences ended this year so other manufactures can now make them)

Preventative Medications

This is by no means an exhausted list – I have simply listed the most commonly used medications. In all cases only your doctor can advise on which you should try.

Beta Blockers – For example; Atenolol, Propanolol, Nadolo or Timolol were originally developed to treat patients with high blood pressure. But, like a lot of preventative medication, they have been found to help with the prevention of migraine.

They block or prevent the widening of arterial blood vessels in the body and reduce activity of the brain cells involved in migraine.

Anti-convulsants-  For example; Sodium Valproate (Epilim), Topiramate (Topamax) and Gabapentin (Neurontin) These were originally developed to treat patients with epilepsy. But, like a lot of preventative medication, they too have been found to help with the prevention of migraine if given in low doses.

It is unclear how they work; they may reduce the capacity of the nerves to transmit pain signals in the brain.

Tricyclic Anti Depressants (TCAs) – For example; Amitriptyline, Dosulepin or Nortriptyline are often prescribed in low doses as a prevention of migraine, being given these does not mean you are depressed! In the same way as being given Epilim does not mean you have epilepsy!

TCAs are thought to block the re-uptake of 5-HT and may block 5-HT2 receptors – Serotonin (5-HT)  is a chemical occurring in the body, which is thought to play a key role in migraine.

Serotonin (5HT) Agonists For example: Pizotifen (Sanomigran) and Methysergide (Deseril). Serotonin (5-HT) is a natural occurring chemical in the body, which is thought to play a key role in migraine.  Serotonin (5HT) Agonists block 5-HT2 receptors to stop the effects of 5-HT.

Pizotifen (Sanomigran) and Methysergide (Deseril) are the usual ones prescribed. Pizotifen also has anti-histamine properties and is related to the Tricyclic antidepressants.

Methysergide is a semi synthetic ergot alkaloid. It is administered under hospital supervision because of the side effects (retroperitoneal fibrosis and fibrosis of heart values and pleura). It must be discontinued for at least one month in six because of the potential side effects.

Calcium Channel Blockers For example: Flunarizine or Verapamil. They work by reducing the calcium entry into neurons making them less ‘excitable’ and block dopamine receptors in the brain.

Verapamil is particularly effective in treating familial hemiplegic migraine.

Flunarizine is one of the most effective in migraine prevention, however, it is not available in the UK! Although, all is not lost, you may be able to obtain it from your neurologist.

Hospital Procedures

Occipital Nerve Block Injection (ONB) This is an injection given into the occipital nerve at the back of the neck, behind the ear. It works by chemically blocking the migraine pain pathway.

Dihydroergotamine (DHE) is an ergot alkaloid. It is similar to sumatriptan but also interacts centrally with dopamine and adrenergic receptors. It can be used to try and break the cycle of a prolonged migraine attack, acute intractable headache or withdrawal from analgesics. It is given via IV over a 5 day (ish) period, hence it is given in hospital.

Patent Foramen Ovale (PFO Closure) Recent research found a link with a common, and usually harmless, defect of the heart to migraineurs.

A PFO occurs in about 1/4 of the population and can allow blood clots to move through blood vessels in the body. It is thought that small blood clots (micro embolisms) may trigger migraine attacks. Retrospective research has shown that some people who have had PFO closure for health reasons other than migraines have reported a reduction in frequency and severity of migraine attacks.

BOTOX® (Botulinum toxin type A) Although known for its use to reduce wrinkles, a number of trials have recently been carried out and have resulted in it recently being approved by NICE as a new treatment for chronic migraine suffers.  It is given via injections (minimum 30) in the forehead, side of head, back of head, neck and shoulders. This has to be repeated on average every 3 months. It is not sure how it works.

Occipital Nerve Stimulation (ONSI) Normally the last resort  and difficult to get –  and only used on a subset of patients who either do not achieve adequate pain relief or cannot tolerate the side effects of typical migraine medications or Patients whose migraines are refractory.

This surgical procedure implants a thin wire containing electrodes under the skin in the back of the head.  The wire extends to an implantable battery-driven impulse generator. Using a removable handheld programmer, the patient controls the rate and intensity of the pulses. It works by targeting one or more of the occipital nerves (greater, lesser, and third occipital nerves) which are transmitting most of the pain. In certain headache syndromes, other nerves may be targeted (for example the supraorbital and supratrochlear nerves). It works by sending a small amount of electrical current to these nerves, which helps to mask the pain. This procedure is ordinarily non-destructive and reversible.

 

Notes:

[1] Chronic migraine is a distinct and relatively recently defined sub-type of Chronic Daily Headache. The International Headache Society defines chronic migraine as more than fifteen headache days per month over a three month period of which more than eight are migrainous, in the absence of medication over use. Episodic migraine is the other migraine sub-type, which is defined as less than 15 headache days per month

(Migraine Trust)

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