Migraines;Strategies to Treat It and Bear It

Migraine: Strategies to Treat It and Beat It

Last week, I talked all about migraine. What do I hope were the takeaways? Well, there are roughly 10,000 known human diseases under the sun… of allll those diseases, I hope you learned that migraine is a very unique beast, thanks to a very unusual constellation of facts surrounding it: its striking capacity to debilitate (ranked first in neuro and sixth overall) and staggering prevalence (ranked third overall) despite a frighteningly high (60%-70%) rate of misdiagnosis really make it a beast of a neurological disease. 

This week, the focus will be on how to manage and/ or prevent migraine. I’m going to cover some basic suggestions and nonprescription ways to avoid or prevent migraine, and I’m also going to discuss some prescription medications and procedures to treat migraine when it occurs. Spoiler alert: one of the very new migraine meds has been like a miracle in my life people. So read on to find out how you might be able to avoid getting a migraine as well as some ways to deal with it once it rears its ugly head. 

First, a few more takeaways from part 1: 

– Migraine is more than a bad headache. 

– Proper and early diagnosis by a specialist physician with specific neuro symptoms is very important. 

– Episodic migraine occurs once or twice a month while chronic daily migraine is minimum 15 days per month. 

– There are several migraine types classified mainly by presence or absence of neurological aura. 

– Migraineurs often have identified triggers that will cause attack. 

– All migraines suck, but some more so than others (hello cluster, rebound, and status migrainosus) because of the extreme pain, but also because of the extreme neurological disturbances that come along for the ride. 

– Exact cause of migraines still unknown, but thought related to a combination of genetics, neurotransmitters, and/ or hormones. 

– There are medications to prevent, abort, and rescue from migraine.

Why isn’t there an obvious known way to prevent and treat migraine?

When people find out I have cluster headaches or when I’m asked by a fellow migraineur or a patient why we don’t already have a foolproof way to prevent and treat migraine, the answer is intensely unsatisfying, especially considering that migraine affects zillions of people, and has done so for a looong time. For the love of Pete, why haven’t we figured it all out by now? Well, even though it is the world’s most common cause of neurological disability, researchers are only just beginning to understand what really causes migraine. I say ‘really’ because unfortunately, the common and long accepted vascular explanation for migraine had to be thrown out relatively recently. The vascular theory was proposed in 1938 and claimed that pressure changes in the vascular system near the brain, and in the brain, caused migraine. More specifically, that vasospasm and vasoconstriction narrowed the blood vessels, slowing and restricting blood supply in and around the brain and causing visual aura and other neuro symptoms; then vasodilation occurred, and those vessels rebounded and widened, allowing too much blood to course through too quickly and causing pain. Eventually, the vessels came back to their normal size and state and the migraine ended…until the next time. This vascular explanation had considerable intuitive appeal because alteration in blood flow seemed to fit the pulsating pain quality that migraine headaches often possess. But now after extensive testing, this theory no longer has any validity. We now know for sure that migraine is a gene-related neurological disease, not a vascular one. So we lost a lot of valuable time looking at the wrong culprit and screwing around with the vascular theory.  

Current research shows that a variety of genetic mutations are at least partly responsible for migraine, with the TRESK gene being identified as one such genetic mutation site. The TRESK gene provides the blueprints for a potassium ion pump channel that is believed to help nerve cells rest. When mutations occur in this gene, they may cause nerve cells to become overexcited, making them more responsive to a smaller pain stimulus or less pain. Personally, I would call that over-reactive rather than overexcited, but that’s just me. Either way you get the idea. Even though genetic mutations tell part of the story, migraine initiation is enormously complicated. It relies on several processes which either result in a visibly changed brain structure or are caused by these changes in structure. In fact, it seems that most scientists believe as I do, that there isn’t just a single cause. In my thinking, there can’t be- there are so many different systems and senses affected that there have to be multiple causes in play. Obviously, lots of research is still needed before we know the whole story. 

Treating Migraine: Natural Remedies

When a migraine does strike, you’ll do almost anything to make it go away. There are ten natural remedies and at-home treatments that may help prevent migraines, or at least help reduce their severity and duration. 

1. Know and avoid triggers, esp in diet

Diet plays a vital role in preventing migraines. Many foods and beverages are known migraine triggers, such as:

-Foods with nitrates, including hot

dogs, deli meats, bacon, and sausage

-Chocolate

-Naturally-occurring tyramine compound, such as blue, feta, cheddar, Parmesan,

and Swiss cheese

-Alcohol, especially red wine

-Foods that contain the flavor enhancer monosodium glutamate (MSG) 

-Foods that are very cold such as ice

cream or iced drinks

-Processed foods

-Pickled foods

-Beans

-Dried fruits

-Cultured dairy products such as

-Buttermilk, sour cream, and yogurt

-Caffeine: a small amount of caffeine may ease migraine pain in some people, and a small amount of caffeine is found in some migraine medications. But too much caffeine may also cause a migraine and/ or may also lead to a severe caffeine withdrawal headache.

**Track yourself! As Migraine Warriors, we tend to think of the occasions when attacks occur and the major symptoms that go along with them. Always keep a diary or list of things that act as warning signs or triggers of an oncoming migraine, including foods or environmental triggers, how much sleep have you had, what the weather is like, what you ate and when, etc.  To figure out for the first time which foods or beverages may trigger your migraines, keep a daily food diary. Record everything you eat and note how you feel afterward. All information may be very important and will likely help you to avoid future attacks.

2. Apply lavender oil

Inhaling lavender essential oil may ease migraine pain. According to a 2012 study, people who inhaled lavender oil for 15 minutes during a migraine attack experienced faster relief than those who inhaled a placebo. Lavender oil may be inhaled directly or diluted and applied to the temples.

3. Try acupressure or acupuncture

Acupressure is the practice of applying pressure with the fingers and hands to specific points on the body to relieve pain and other symptoms. While there are no recent scientific studies, according to some sources, acupressure is a credible alternative therapy for people in pain from chronic migraine and other conditions, and may also help relieve migraine-associated nausea. And although there may not be any definitive  scientific studies on acupuncture, some migraines may respond well to acupuncture, the Chinese method of inserting needles into specific body locations to reduce or stop pain. Because the results are so variable, some doctors do not recommend this treatment. But because some patients report headache relief, it is another treatment method to consider.

4. Look for feverfew

Feverfew is a flowering herb that looks like a daisy, and according to some, is a folk remedy for migraines. According to some sources, there’s not enough evidence that feverfew prevents migraines, but many people still claim it helps their migraine symptoms without side effects.

5. Apply peppermint oil

The menthol in peppermint oil may stop a migraine from coming on. A 2010 study found that applying a menthol solution to the forehead and temples was more effective than placebo for the pain, nausea, and light sensitivity associated with migraine. 

6. Go for ginger

Ginger is known to ease nausea caused by many conditions, including migraines, and it may also have other migraine benefits. One study claimed that ginger powder decreased migraine severity and duration as well as the prescription drug sumatriptan, and with fewer side effects.

7. Sign up for yoga

Yoga uses breathing, meditation, and body postures to promote health and well-being and may relieve the frequency, duration, and intensity of migraines. It’s thought to improve anxiety, release tension in migraine-trigger areas, and improve vascular health. Although researchers conclude it’s too soon to recommend yoga as a primary treatment for migraines, they believe yoga supports overall health and may be beneficial as a complementary therapy.

8. Try biofeedback

Biofeedback is a relaxation method that teaches you to control autonomic reactions to stress. Biofeedback may be helpful for reducing migraine triggers like stress and early migraine symptoms such as muscle tension.

9. Take vitamins and supplements

Some vitamins and supplements (collectively known as nutraceuticals) may be useful therapies. One of the nutraceuticals that has shown some evidence of relief in preliminary testing is magnesium. Magnesium deficiency is known to be linked to headaches and migraines and studies show magnesium oxide supplementation helps prevent migraines with aura, and may also prevent menstrual-related migraines. Adding magnesium to your diet may be helpful. You get magnesium from foods like nuts and nut products, including almonds, sesame seeds, sunflower seeds, Brazil nuts, cashews, peanut butter, eggs, oatmeal, and milk.

10. Book a massage

A weekly massage may reduce migraine frequency and improve sleep quality, according to a 2006 study. The research suggests massage improves perceived stress and coping skills and also helps decrease heart rate, anxiety, and cortisol levels.

The Takeaway

If you get migraines, you know the symptoms can be challenging to cope with. You might miss work or not be able to participate in activities you love. Try the above remedies to possibly find some relief… they can’t make it much worse!

It might also be helpful to talk to others who understand exactly what you’re going through. There are lots of websites, support groups, and apps to connect you with real people who also experience migraines. You can ask treatment-related questions and seek advice from other people who totally “get it.” So do some googling for migraine support. 

Calculate your Headache Burden

Another good idea… Some doctors like to estimate how much migraine disrupts your normal activities before establishing a treatment regimen. A questionnaire may be given to the patient to estimate how often they miss various functions (school, work, family activities) because of their attacks. You can also commonly find other surveys and tools online meant to be filled out, printed, and brought to a primary care physician to broach the subject of headache and/ or to discuss migraine types with specialist physicians to help define headache/ migraine type and zero in on the best treatment regime.

Treating Migraine: Medications

There are many types of medications for people with migraine headaches. Some help to reduce symptoms of acute migraine as they occur, while others prevent episodes from occurring. Captain Obvious says that taking any drug can have side effects, and that some are safer than others.

Two primary ways that medications treat migraine headaches: Acute medications aim to treat symptoms of migraine headaches as they occur. Preventive medications aim to reduce the risk of migraine headaches occurring in the first place by reducing migraine frequency and severity.

Over-the-Counter (OTC) Medications

-Acute medication to treat migraine

-A range of migraine medications are available without a physician’s prescription. 

-These include analgesic medications like aspirin, acetaminophen, naproxen, or ibuprofen, may help to reduce pain. 

-Many of these analgesic medications are nonsteroidal anti-inflammatory drugs (NSAIDs). This means that similar to steroids, they reduce inflammation which may help with migraine symptoms. 

-It is best to take these medications when the first signs of an episode occur. The medicines will take time to enter the bloodstream, and taking them too late means that the headache will likely last longer and possibly won’t be susceptible to the medication; in other words it may not help. 

-The risks associated with using OTC analgesics are relatively low. 

-May cause mild side effects in some people, such as rashes.

When over-the-counter (OTC) medications do not work, a doctor may recommend stronger prescription drugs. There are several different types of prescribed migraine medications.

Prescription Medications: Treat Migraine

As opposed to preventing migraine

Ergot Alkaloids: Treat Migraine

-Medication to treat acute migraine

-I want to point out that ergot drugs are really old school. The American Migraine Foundation wants to point out that doctors don’t commonly prescribe them any longer, but they may recommend them in severe cases if someone doesn’t respond to other analgesics.

-Two main types are dihydroergotamine (DHE)  and ergotamine (Ergomar)

-Ergot alkaloids may cause blood vessels to narrow, which can have serious side effects for people with cardiovascular disease issues.

-Other potentially serious side effects: nausea, dizziness, muscle pain, unusual or bad taste in the mouth, vision problems, confusion, unconsciousness, in addition to many drug interactions.

-These side effects and the drug’s interactions are so problematic that physicians typically severely restrict use of ergotamines except in very rare cases.

-Fun fact: many scholars claim that the behavior of Salem’s “witches” was actually due to a fungal infection in the grain used at the time; ergotamines are essentially a mimic of this grain infection. So maybe don’t take it unless you look good in black and like the pointy hat look. Yikes people! Because of the side effect profiles and lack of efficacy, this class is definitely not as commonly used as newer and more effective triptans and more novel compounds.

Triptans: Treat Migraine

-Acute medication to treat migraine

-Approved to treat moderate to severe migraines: headaches where the symptoms interfere with the ability to perform daily tasks.

-Triptans act on the symptoms of a migraine headache in its early stages. -They will not stop the migraine headache, but they can help with some symptoms, such as nausea, pain, and light sensitivity. 

-Several triptan medications exist:

sumatriptan (Imitrex)

zolmitriptan (Zomig)

rizatriptan (Maxalt)

-A person should take these drugs as soon as migraine symptoms start. 

-They may not work if taken during a migraine aura. 

-They are available in several forms: pill, orally disintegrating tablet, nasal spray, or injection.

-Triptans can cause side effects: dizziness, fatigue, nausea and vomiting, pain in the throat, chest, or head, numbness, dry mouth, burning or prickly feeling on the skin, indigestion, hot flashes, chills.

Antiemetics/Antinausea: Treat Migraine

-Acute medication for migraine symptoms

-Also known as antiemetic drugs, these can help people with migraine, even if they don’t feel nauseous. 

-Don’t reduce pain, so some people take them alongside pain relief medication.

-Examples of antiemetic drugs:

chlorpromazine (Thorazine)

metoclopramide (Reglan)

prochlorperazine (Compazine)

promethazine (Phenergan)

CGRPReceptor Antagonist: Treat Migraine

-The FDA has recently approved several drugs that block calcitonin gene-related peptide (CGRP) receptors for the immediate treatment of migraine.

-CGRP is a molecule typically involved in migraine episodes.

-Examples of recently approved CGRP receptor antagonists include ubrogepant (Ubrelvy) and rimegepant (NURTEC).

Ubrogepant (Ubrelvy): Treat Migraine

-First drug in the class of oral CGRP (calcitonin gene-related peptide) receptor antagonists approved for the acute treatment of migraine with or without aura in adults

-Similar to Rimegepant (Nurtec ODT)

-Most common side effects that patients in the clinical trials reported were nausea, tiredness, and dry mouth. 

-Contraindicated for co-administration with strong CYP3A4 inhibitors such as ketoconazole, clarithromycin, and itraconazole.

-Your doctor may change your treatment plan if you also use: nefazodone; an antibiotic – clarithromycin, telithromycin; antifungal medicine – itraconazole, ketoconazole; or antiviral medicine to treat HIV/AIDS – indinavir, nelfinavir, ritonavir, and saquinavir.

Rimegepant (Nurtec ODT): Treat Migraine

-CGRP receptor antagonist used for acute treatment of migraine with or without aura in adults. 

-Similar to ubrogepant (Ubrelvy)

-Orally Disintegrating Tablets (ODT) for sublingual or oral use.

-Side effects include: nausea and

hypersensitivity, including shortness of breath and severe rash

-Important: like Ubrelvy, Nurtec will interact with other medicines such as: strong CYP3A4 inhibitors and moderate CYP3A4 inhibitors such as ketoconazole, clarithromycin, and itraconazole. Will also interact with inhibitors of P-gp or BCRP.

**This is the new medication for treating migraine that works like a miracle for moi people!

Lasmiditan (Reyvow): Treat Migraine

-First in a brand-new class of drugs (Ditans) that stimulate the serotonin 1F receptor found in different brain regions and believed involved in causing migraine

-Slows body’s pain pathways

-Used for acute treatment of migraine with or without aura in adults. 

-Not useful for migraine prevention. 

-Taken by mouth 

-Common side effects: sleepiness, dizziness, tiredness, numbness

-Reduces inflammation that arises in the nervous system. 

Prescription Medications: Preventing Migraine

-For people who get migraine headaches regularly, some medications can help to reduce the number and severity of episodes, ie prevent migraine.

-Most drugs for preventing migraine headaches are relatively low risk.

-May cause side effects such as constipation, muscle spasms, and cramps.

-Several categories of preventative medications:

Antihypertensives

-Antihypertensive drugs lower blood pressure, usually in people with high blood pressure. 

-There are many different types of antihypertensive drugs that might help to prevent migraine headaches, such as: beta-blockers, calcium channel blockers, and angiotensin-converting enzyme (ACE) inhibitors

Anticonvulsants

-Anticonvulsant drugs treat seizures in people with epilepsy by reducing activity in the brain- and this can also reduce the risk of a migraine headache.

-Examples of anticonvulsants for treating migraines include topiramate (Topamax) or valproic acid (Depakene).

Antidepressants

-Antidepressants often work to increase the availability of serotonin in the brain. -Because of this mechanism, some of these drugs could also help to prevent migraine headaches, such as amitriptyline (Elavil).

CGRP inhibitors

-Calcitonin Gene-Related Peptide

-CGRP inhibitors are preventive migraine treatments that disrupt a protein called CGRP, which is particularly active in people with migraines.

-They block the flow of CGRP to the brain, disrupting signals that cause migraines.

-Unlike traditional migraine meds, such as sumatriptan (Imitrex), CGRP inhibitors don’t constrict blood vessels, so they’re safe for people who’ve had a stroke, heart attack, or vascular disease.

-Three new CGRP inhibitors are injected once a month to prevent migraines:

erenumab (Aimovig) 

fremanezumab (Ajovy) galcanezumab-gnlm (Emgality)

-So new: may cause unknown side effects, and consequences of long-term use are still unknown. 

Eeptinezumab-jjmr (VYEPTI)

-FDA 2020 approval, migraine prevention in adults

-First drug for migraine prevention via IV infusion.

-Treatment involves doctor administering this drug intravenously for 30 minutes every 3 months.

Devices: Treat/ Prevent Migraine

-There are three new noninvasive medical devices currently available:

Cefaly

-Placed on the forehead to stimulate a nerve that impedes migraine pathways. 

-Used as prevention or for treating when a migraine strikes.

-SpringTMS

-Magnetic stimulator placed on the back of the head to disrupt migraine signals in the brain.

-Used as prevention or for treating when a migraine strikes.

gammaCore

-Third device

-Used for treating when a migraine occurs, cannot prevent migraine

-Placed at front of the neck to stimulate the vagus nerve. 

Procedures: Preventing Migraine 

There are two profedures used in an attempt to prevent migraine by reducing frequency and severity.

SPG Nerve Block

The sphenopalatine ganglion (SPG) is a group of nerve cells linked to the trigeminal nerve. 

-Applying local anesthetics to this group of nerve cells can reduce sensations of pain related to migraines.

-Doctors can apply medication to this area through the use of small tubes called catheters. They can place these tubes inside the person’s nose, then insert numbing medication through the tube using a syringe.

Botox Injections

-OnabotulinumtoxinA (Botox) injections for people with chronic migraine headaches. 

-Doctor might prescribe Botox if a person has experienced at least 15 headaches per month for 3 months, eight of which must have included migraine symptoms.

-Doctors tend to recommend two or three other types of medication before trying Botox injections.

-Comes as injection only, can have many side effects.

-Progress carefully monitored, treatment may be stopped if there is no response after 8–12 weeks or if migraine episodes fall to less than 10 per month for 3 months.

-Can also have many possible side effects, including numbness or mild nausea. -Some other side effects are more serious, such as gallbladder dysfunction, visual problems, and bleeding.

Your Migraine Treatment: Is it Working?

-Sometimes initial treatments for migraine either do not reduce the symptoms or only marginally reduce them. 

-If, after trying prescribed treatment(s) about two or three times and getting little or no relief, you should ask your doctor to change the treatment.

-Patients are strongly urged to treat migraine attacks early: some references indicated to take it within about 2 hours of the start of headache to get full benefit of treatments.

-Taking it earlier is better: as early as possible.

Migraine Treatment: Medication Limits

-Some chronic headaches are due to overuse of medicine

-Avoid using migraine-prescribed medicines more than twice per week. -Using and tapering medicine for migraine should proceed under your doctor’s supervision. 

-Narcotics are a bad idea except used only as a last resort for migraine because they are addictive and very easily cause rebound headache pain. For example, only in an emergent situation, an ER visit.

Migraine: When to Seek Emergent Care

Most people know the pattern of their attacks (triggers, auras, and headache pain intensity). However, new headaches, in people with or without a migraine history, that last two or more days should be checked by a doctor. However, if a headache develops with symptoms such as fever, stiff neck, confusion, or paralysis, the person should be examined emergently and should be taken to an Emergency Medicine Department for scans and thorough evaluation.

Okay people, now you know pretty much everything about migraine… I hope it’s information you don’t need for yourself, and that you can tuck it away in your brain for the who knows when future. If you learned something, great! If you’re interested in a blog about a specific topic, please feel free to leave that in this comments section and I’ll see what I can do. And don’t forget about the sex and orgasm survey people! We need people to agree to be contacted once we finish it, so leave that in the comments too if you’re willing to takw it. Please pass this blog on to friends and fam. And definitely check out my YouTube channel for all of my videos and please like, comment, and share those too. As always, my book Tales From the Couch is available on Amazon and in the office. 

Thanks people!

MGA