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Update on Migraine Treatment

June 18, 2024

Nearly 12% of people in the United States experience migraine, and 8% of those have chronic migraine. The condition can be confounding to diagnose and treat, and as many as 50% of migraine sufferers don’t seek help. However, new treatment options—such as Botox® and CGRP monoclonal antibodies—are showing great promise.

Diagnostic criteria well established

Migraine is distinguished from other headaches by its definition as a headache attack lasting longer than 4 hours, with at least 2 of the following:

  • Moderate to severe pain
  • Unilateral pain greater than bilateral pain
  • Pulsating and/or throbbing
  • Causing the avoidance of daily activities

In addition, the headache must meet 1 of the following criteria:

  • Causing nausea and/or vomiting
  • Causing sensitivity to light (photophobia) and/or sound (phonophobia)

Finally, the headache must not be caused by something else, which often presents the greatest challenge. Some of the red flags indicating other possibilities are:

  • Headaches with high fever
  • Headaches in people who have cancer or are pregnant or immunocompromised
  • Sudden onset of headache at age 50 or older
  • Headaches that wake the patient from sleep are worsened when lying down or are associated with focal neurological signs
  • Pain described as the worst headache of the patient’s life

These situations suggest the possibility of a tumor, infection or intracranial hypertension.

Imaging is not always necessary to confirm a migraine diagnosis. Generally, we recommend imaging when migraine frequency increases rapidly in a previously stable patient, when headaches begin in an older patient and when the migraine is accompanied by dizziness, lack of coordination, numbness or weakness on 1 side.

Reduction strategies start with adjusting behavior

Upon initial diagnosis, many patients can benefit from following these recommendations:

  • Sleep at consistent times every day.
  • Get 6-8 hours of sleep each night.
  • Consider obstructive sleep apnea as a cause.
  • Stay hydrated by drinking at least 6 8-ounce glasses of noncaffeinated liquid per day.
  • Limit daily caffeine to 1-2 drinks per day. Avoid processed foods.
  • Get regular, moderate exercise.
  • Keep a headache diary, noting length of the attack, days per month, associated symptoms and dietary or environmental triggers.

Treatment options based on abortive vs. prophylactic need

If the patient has rare or periodic attacks, we often consider acute or abortive therapy. Initially, we can try nonsteroidal anti-inflammatory options, magnesium, diphenhydramine and sometimes an antiemetic. OTC migraine preparations containing aspirin, acetaminophen and caffeine also are often effective.

In some cases, we may recommend serotonin receptor antagonists, or triptans, such as Sumatriptan, or newer options that work on CGRP, such as Rimegepant, Ubrogepant or Zavegepant. Antiemetic drugs also may be considered as additional therapies.

Abortive or acute therapies are not considered effective if the patient continues to have 1 or more of the following:

  • More than 2 attacks per month that significantly affect daily activities
  • Attacks more than 4 times per month
  • Poor response to acute therapy
  • Contraindications to acute therapy
  • Needing to use acute therapy more than 2 times per week

If the above occurs, we will likely recommend prophylactic therapy, such as antihypertensives, antidepressants or antiepileptic treatments to help prevent migraines. (Note: With antiepileptics, add calcium and vitamin D replacement.) Some patients find relief with relaxation training, acupuncture, massage, physical therapy or biofeedback conducted by a pain psychologist.

Botox® treatment shows promise

The FDA approved prophylactic treatment of migraine with Botox in 2010, and we have found great success in some patients. It is generally indicated for patients with chronic migraines, defined as headaches of more than 4 hours each occurring more than 15 days per month for greater than 6 months. The therapy calls for 31 injections with a total of 155 units every 12 weeks. The injections, delivered to specific sites on the front and back of the head and neck, take about 10 minutes. This therapy has been shown to reduce migraine frequency by an average of 8 days per month.

We have had several success stories with Botox in our practice. As an example, we are treating a female in her late 20s with a prominent professional role who had daily headaches, causing her to miss an average of 4 days per month of work. After a little less than a year of quarterly Botox therapy, she now has just 3 or 4 headaches per month, she uses a triptan sparingly, and she has stopped missing work due to headaches. Recently, she reported just 4 headaches in a 6-week period. Although her case is an exceptional response, many patients do see some benefit.

Referral indicated in some cases

If the potential abortive therapies are not working and a patient has failed on at least 1 prophylactic option, a referral for a neurological workup may be indicated. We often provide a second opinion to physicians who are concerned about potential red flags, failure of the therapies described here, abnormal side effects or other chronic comorbidities. We work closely with primary care providers and are happy to collaborate on headache care.

Medically reviewed by Deetra Ford, MD, a neurologist with The University of Kansas Health System. She is certified by the American Board of Psychiatry and Neurology.

To consult with one of our neurologists, please call 913-588-5862, or toll-free 877-588-5862

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