Many factors may contribute to the occurrence of migraine attacks. They are known as trigger factors and may include diet, sleep, activity, psychological issues as well as many other factors. The use of a diary to record events that may play a role in causing the headaches can be a useful tool for the patient and healthcare provider. Avoidance of identifiable trigger factors may reduce the number of headaches a patient experiences. Healthful lifestyles including regular exercise and avoidance of nicotine may also enhance migraine management. Non-pharmacological techniques for control of migraine are helpful to some patients. These include biofeedback, physical medicine, and counseling. These, as with most elements of migraine, need to be individualized to the patient.
If patients have more than two migraine attacks per month then preventive medications should be given to reduce migraine. Other considerations include whether the attacks do not respond consistently to acute treatments or are prolonged over several days, if the migraine-specific medications are ineffective or contraindicated because of other medical problems. Cost considerations also may lead to increased use of preventive medications. Preventive medications are taken on a daily basis.
While many drugs are used to prevent migraine, only three have FDA approval for migraine prevention. They are propranolol, timolol and divalproex sodium. These have had many years of use and are considered “first line” therapy for migraine prevention. Currently, clinical trials are being conducted on topiramate and botulinum toxin.
There are a host of alternative choices for patients whose headaches do not respond to the first line medications. These include anticonvulsants, beta blockers, calcium channel blockers, NSAIDs, antidepressants and several other medications. These medications are all available in tablet form.
All migraine preventive medications require that adequate doses of the medicine be given for a sufficient length of time to determine the effectiveness. Titration of the doses may be needed to reduce adverse effects to medicines.
Triptan medications are migraine-specific and are taken at the start of an attack to reduce the severity or duration of the headache. These medications are available in self-injectable, nasal spray, orally disintegrating tablet and tablet forms.
Ergotamine preparations are available for oral or rectal administration, and dihydroergotamine (DHE) may be used for self-injection. It is also available as a nasal spray. A combination product containing isometheptene may be used for those unable to tolerate the ergotamine preparations.
The use of the anti-inflammatory agents such as aspirin, naproxen sodium or ibuprofen may be effective for some migraines. These agents may have gastrointestinal side effects, which limit their use since larger than normal doses may be required to treat the migraine attack.
Some attacks may not be eliminated by abortive therapy, yet the patient requires pain-relieving measures. Due to the severity of the headaches, some patients may require a narcotic analgesic, but if the patient is experiencing frequent migraine attacks habituating analgesics and pain relievers should be avoided. Alternative medical treatments with medications belonging to the group known as the phenothiazines have proven useful as non-analgesic options for treating severe migraine headaches.
The Food and Drug Administration (FDA) has approved three over-the-counter products to treat migraine including a combination of aspirin, acetaminophen and caffeine and two products containing ibuprofen.
Non-Medicated Therapies as an alternative to drug therapy, modalities such as biofeedback, relaxation training, guide imagery and counseling are often used. Diet control, maintaining a regular sleep/wake cycle as well as exercise, diaphragmatic breathing and acupuncture are other methods of non-pharmacologic treatments. These modalities are frequently used in conjunction with medications.