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Medicating for Migraines

In part one of this post, we talked about the nature of migraines — where they come from, and what models physicians are using to approach them. In this part, we look at the complexities inherent to medicating something that’s such a moving target.

When it comes to medicating migraines, there are three types of treatment: preventive, abortive, and rescue.

Preventive is pretty much what it sounds like: You take medication regularly to keep migraines generally at bay. Abortive is for when the preventive medication doesn’t work and you feel a migraine coming on. Rescue is, to some extent, a concession that the migraine has won. These are typically geared toward pain and nausea relief if abortive measures have failed.

It should come as no surprise, but the multifaceted nature of migraines makes them pretty hard to treat with any given medication.

“You have to keep in mind that the complexity of migraines means you have to be able to treat multiple things,” said Roderick C. Spears, MD, FAHS, clinical associate of Neurology. “That’s what’s great about triptans, which I consider first-line treatment. They go right to the part of the brain that controls migraine, and they stop not just the pain but the nausea, vomiting, light sensitivity … the entire spectrum. By comparison, Advil is not going to do something like that.”

Triptans have emerged over the past few decades as one of the more effective treatments for a range of migraines, as they’ve been found to interfere with pain signaling and certain peptide releases within the meninges. Myriad studies over that span of time have found triptans to be effective at reducing or eliminating migraines in anywhere from 40-70 percent of patients who hadn’t responded to other treatments, making them a strong go-to option. What’s more: They’re also migraine-specific.

That’s more important than you might think. Medications specifically designed to attack migraines are emerging, but are still rare at the moment. Spears noted that there simply aren’t many medications that are FDA approved or on-label for migraine prevention. Many of the medications that have been used on migraines were intended to tackle another issue and just happened to be handy for tackling migraines as well.

“Most of them are designed for something else, but we know from clinical practice and experience that they are effective to prevent migraines,” Spears said.

On the other hand, triptans don’t target much of anything aside from the migraine itself. That sets them apart, and makes them a strong candidate for the use of severe migraine treatment.

“Severe” is an important distinction there, because according to Swathi Vijayaraghavan, MD, an assistant professor of Clinical Neurology, the severity of the migraine is just one of the many factors to take into account when trying to treat for it.

“My take on it is you have to find the right combination of medications both for acute and preventive treatments for each person,” she said. “What works for you might not work for the next person. We have to work through adjusting to different doses of medications. You can’t just do one-size-fits-all treatment with migraines.”

Determining the nature of the patient’s migraine experience is part of this process. Physicians will ask patients to start maintaining a headache journal. Did you have a migraine today? How bad was it, on a scale from one to ten? Is it the only one you’ve had this week? This month? Did you eat, do, or experience anything that might have triggered it?

That’s important information because, according to Vijayaraghavan, patients whose migraines are relatively mild and infrequent may not need to be medicated at all. For these patients, taking a nap or using a cold or warm compress may be enough.

For patients who get moderate to severe migraines — or experience migraines frequently, for more than fifteen days out of the month — it becomes more about the type and strength of the medication you’ll end up with. Patients who are dealing with migraines and migraine symptoms for more than half the month or are suffering from three or more debilitating migraines a month are usually placed on preventive medication, which works to make migraines both less common and less debilitating.

“The goal is, over time, to decrease how often you’re having your headaches and how severe your headaches are — so your as-needed drugs have a better shot of working,” Vijayaraghavan said.

Spears mentioned Advil earlier, and for good reason: While it makes sense someone would jump toward something like Advil or Excedrin to handle their most overwhelming symptom (pain), they may be causing more issues than they’re resolving.

“Things like Excedrin are not migraine specific,” Spears said. “They help with the pain, but don’t stop the underlying process, so it allows the migraine to continue to move forward and develop into a headache more severe than it’d be otherwise.”

On top of that, Spears pointed out, patients who chase after their migraines with pain medication for more than two days out of the week run the risk of developing medication overuse headaches. Then you end up taking pain medication for that headache, and things spiral — and all the while, you still haven’t met the migraine at its source.

Overuse of pain medication isn’t the only complicating factor, either: Because nausea and vomiting are such a significant part of attacks for many migraineurs, researchers have had to develop different modalities for medication ingestion.

“There are tablets, of course, but injectables are available, as well,” Spears said. “There are nasal sprays, nasal powders … I even have some patients that use suppositories. You have to keep an open with delivering the medication.”

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