Articles

Migraine: Current Treatments and Future Therapies

By Katie Golden

There are two main categories of current migraine treatments: preventatives and abortives.

Preventatives are taken daily to ward off a migraine attack before it starts. In many circumstances, an attack can still occur, but the aim of preventatives is to reduce the frequency.

Abortives (also known as rescue medications) are taken when a new, active migraine attack begins. It is important to take an abortive at the very first sign of an attack for it to be most effective.

Below are the current types of preventative and abortive medications available to those with migraine.

 

Preventatives

All preventative medications prescribed for migraine were originally approved for other uses. They are used off-label for migraine. It is not completely clear why the types of drugs listed below also benefit migraine, but studies have proven they can help decrease the frequency of attacks when taken daily.

 

  • Antidepressant medications such as amitriptyline (Elavil), sertraline HCL (Zoloft), bupropion (Wellbutrin), and paroxetine (Paxil). Side effects can include depression, increased sensitivity to light, insomnia, and dry mouth.
  • Anti-seizure medications such as valproic acid, gabapentin, and topiramate (Topamax). Side effects can include trouble finding words, memory problems, tremor, and hair loss.
  • Beta blockers such as propranolol and timolol. These drugs reduce blood pressure and slow the heartbeat. Side effects can include fatigue, memory problems, depression, and weight gain.
  • Supplements such as feverfew, butterbur, magnesium, Coenzyme Q10, and riboflavin. While these are available over the counter, you should talk to a doctor before taking any of these drugs, to account for potential side effects or contraindications.
  • Botox, which is a proven preventative therapy. Patients receive over 30 shots of the medication in their forehead, temples, scalp, shoulders, and masseter muscle to deaden the nerve endings. Botox is only approved for use every 12 weeks and prescribed for those who have chronic migraine (15 or more migraine days per month).
  • Nerve blocks, which are injections administered in similar areas to those used in Botox treatment. Nerve blocks use lidocaine to help quiet the nerve endings, but the effects do not last as long as Botox.

Abortives

It is important to limit the number of days abortives are taken in a month’s time, because taking these drugs too often can cause medication overuse headache (MOH) and increase the frequency of migraine attacks from episodic to chronic.

  • Triptans such as sumatriptan (Imitrex), almotriptan malate (Axert), sumatriptan/naproxen sodium (Treximet), rizatriptan (Maxalt), and naratriptan (Amerge). This class of drugs was introduced in the 1990s to stop active migraine attacks.
  • Dihydroergotamine (DHE), a medication available as an injection, nasal spray, and IV infusion. It is in the ergotamine (or ergot) class, believed to work on receptors that cause blood vessels to narrow.
  • Painkillers such as narcotics and opioids like oxycodone (Oxycontin), hydromorphone (Dilaudid), morphine, and acetaminophen/oxycodone (Percoset). A majority of headache specialists are opposed to prescribing this class of drugs due to the potential for addiction as well as MOH.
  • Anti-inflammatory medications such as ketorolac (Toradol, Acular, Acuvail), or nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Anti-nausea medications such as prochlorperazine (Compazine), promethazine (Phenergan), and ondansetron (Zofran).

Other Treatment Options

  • Nerve decompression surgery, which is typically performed by a plastic surgeon. The surgery removes muscles in the scalp and neck that are “entrapping” nerves believed to cause migraine attacks.
  • Nerve ablation, a procedure used to inactivate painful nerves that are inflamed during migraine attacks by using special needles to cut off the nerve endings.
  • Surgically implanted stimulators called neurostimulators work to modify nerve signals. These devices change the abnormal pain messages felt during migraine attacks by sending their own electrical impulses in an attempt to redirect the nerve signals and prevent or abort migraine attacks. Candidates for this procedure go through several qualifying steps before undergoing implantation of the device under the skin near the base of the skull.
  • External stimulators (including Cefaly, gammaCore, and SpringTMS) are medical devices designed to interrupt pain signals to prevent or abort migraine attacks. Each device is designed to engage different nerve systems that are known to affect migraine (trigeminal, vagal, and transcranial nerves, respectively). These devices continue to evolve and patients have varying reactions.
  • Ketamine infusions involve an anesthetic drug, and have recently been used at therapeutic levels to treat migraine through IV infusions at headache centers or pain management clinics. Ketamine can cause hallucinations. It is being studied for use in treating complex regional pain syndrome (CRPS), post-traumatic stress disorder (PTSD), and depression. It is just starting to be studied for its use in treating migraine, and the reasons why it helps alleviate migraine frequency and intensity for some patients are not yet fully understood.
  • Medical marijuana, which has not yet been proven by medical research to be efficacious for migraine. Yet, many migraine patients report that marijuana in various forms has eased their symptoms, especially nausea.

Hope for the Future

A new category of prevention options has arrived. Four pharmaceutical companies are in various stages of FDA approval for medicines that would help prevent migraine attacks. If approved, these would be the first drugs specifically designed to prevent migraine.

All formulations target the calcitonin gene-related peptide (CGRP) receptors in the brain. Scientists have discovered that levels of CGRP increase during migraine attacks. The CGRP monoclonal antibodies aim to regulate CGRP output and prevent attacks.

Late 2018 is the earliest these drugs are estimated to be available for the consumer. Many headache specialists believe this is an exciting time for the future of headache medicine, with new medications on the horizon.

 

The U.S. Pain Foundation and the INvisible Project do not recommend any specific modalities for pain treatment. This list is intended to outline some of the available treatment options so patients may research and discuss with their doctors.