Virtual Headache Specialist

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Migraine

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Treatment





  1. Abortive: What to take “as needed” for a headache. The earlier the medicine is taken, the more effective it will be. These are the medications used most commonly, although this is not an all-inclusive list.
    1. Nonsteroidal anti-inflammatory drugs (NSAIDs)/Analgesics:
      ---Diclofenac (Cataflam)
      ---Naproxen (Aleve)
      ---Ibuprofen (Advil, Motrin)
      ---Acetaminophen Extra Strength (Tylenol)
      ---Excedrin (Tylenol +/- Aspirin +/- Caffeine)
    2. Triptans: (Typically considered first-line therapy)
      **Fast onset migraines (within 30 minutes to peak pain), waking migraines, or prominent nausea/vomiting with migraines will all respond best to an injectable or nasal spray form of triptan since these work faster than a pill. The triptans are made for taking at the earliest sign of migraine. The longer the time until the medicine is taken, the less effective it will be.
      ---Sumatriptan pill (Imitrex), injection (Imitrex, Sumavel, Alsuma), nasal spray (Imitrex), breath-powered intranasal delivery system (Onzetra Xsail), transdermal patch using mild electrical current (Zecuity)
      ---Zolmitriptan (Zomig) pill, dissolvable pill, nasal spray
      ---Sumatriptan/Naproxen (Treximet) pill
      ---Rizatriptan (Maxalt) pill, dissolvable pill
      ---Eletriptan (Relpax) pill
      ---Almotriptan (Axert) pill
      ---Frovatriptan (Frova) pill (this can be good for long duration migraines, or menstrual migraine lasting several days)
      ---Naratriptan (Amerge) pill (this can be good for long duration migraines, or menstrual migraine lasting several days)
    3. Ergots:
      ---Dihydroergotamine (DHE) given as self-injections, through an IV coordinated with your doctor, or by nasal spray (Migranal). There is an inhaled form that may eventually become available. This can be good for long duration migraines, or menstrual migraine lasting several days.
      ---Ergotamine/Caffeine (Cafergot). This can be good for long duration migraines, or menstrual migraine lasting several days.
    4. Neuromodulatory Devices:
      ---GammaCore (non-invasive vagus nerve stimulator)
      ---Nerivio
      ---Cefaly (Transcutaneous electrical nerve stimulation device)
      ---Single Pulse Transcranial Magnetic Stimulation (sTMS)
    5. Gepants:
      ---Rimegepant ODT (Nurtec ODT)
      ---Ubrogepant (Ubrelvy)
    6. Ditans:
      ---Lasmiditan (Reyvow)




  1. Preventive treatments: What to take on a daily basis to try to lessen the frequency and/or severity of the headaches. Preventive medicines generally take 4-6 weeks to start working and 2-3 months for full effect, assuming the correct dose of the medication is reached. These are the medications used most commonly, although this is not an all-inclusive list.
    1. Conservative therapy: (these are often very helpful)
      ---Massage, relaxation therapies such as biofeedback, neck physical therapy (if there is a lot of neck tension), acupuncture/acupressure, eliminating caffeine, routine exercise, hydration, weight loss, avoiding triggers, dietary changes, and improved sleep patterns
    2. Anti-convulsant (Anti-seizure) medications:
      ---Topiramate (Topamax) (FDA-approved for migraine prevention)
      ---Divalproex sodium (Depakote) (FDA-approved for migraine prevention)
      ---Zonisamide (Zonegran)
      ---Carbamazepine (Tegretol)
      ---Gabapentin (Neurontin)
    3. Anti-depressant/Anti-anxiety medications:
      ---Amitriptyline (Elavil)
      ---Nortriptyline (Pamelor)
      ---Venlafaxine XR (Effexor XR)
      ---Desvenlafaxine (Pristiq)
      ---Duloxetine (Cymbalta)
    4. Anti-hypertensive (blood pressure) medications:
      ---Propranolol (Inderal) (FDA-approved for migraine prevention)
      ---Timolol (Timol) (FDA-approved for migraine prevention)
      ---Metoprolol (Toprol)
      ---Atenolol (Tenormin)
      ---Nadolol (Corgard)
      ---Lisinopril (Zestril)
      ---Candesartan (Atacand)
      ---Verapamil (Calan)
      ---Acetazolamide (Diamox)
    5. Biologics:
      ---Onabotulinum Toxin A (Botox): This is the only FDA approved medication available for chronic migraine (greater than 15 days per month for 3 or more consecutive months, with 8 of those days having more migrainous features).
      ---CGRP (Calcitonin Gene Related Peptide) Antagonists: Aimovig (Erenumab) once monthly auto injection, Ajovy (Fremanezumab) once monthly auto injection (or 3 doses quarterly), Emgality (Galcanezumab) once monthly auto injection, Vyepti (Eptinezumab) once quarterly IV infusion
    6. Supplements and natural treatments:
      ---For a detailed summary of all the supplements used for migraine prevention, read here.
      ---Magnesium
      ---Vitamin B2 (Riboflavin)
      ---Butterbur
      ---Feverfew
      ---Coenzyme Q10
    7. Neuromodulatory Devices:
      ---Cefaly (Transcutaneous electrical nerve stimulation device)
      ---Single Pulse Transcranial Magnetic Stimulation (sTMS)
  1. General Headache Instructions:
    1. Maintain a headache diary; learn to identify and avoid triggers.
    2. Limit use of acute treatments (“as needed” medications such as over-the-counter medications, triptans, etc.) to no more than 2 days per week or 10 days per month to prevent medication overuse headache (rebound headache).
    3. Follow a regular schedule (including weekends and holidays):
      1. Don't skip meals.
      2. 8 hours of sleep nightly.
      3. Avoid the following common headache triggers:
        -Caffeine (coffee, chocolate, tea, cola/pop/soda (7-up, Sprite, Sierra Mist, Ginger Ale, Mug/A+W Root Beer, Minute Maid Orange, Slice are okay))
        -Foods containing nitrates (deli meat, ham, bacon, sausage, hot dogs)
        -Tyramine (aged cheese; can only have American cheese, cottage cheese, Velveeta and fresh mozarella (most pizza uses aged mozarella))
        -MSG (Chinese/Hispanic foods, Doritos, all flavored chips and Ramen noodles)
        -Nutrasweet and artificial sweeteners
      4. Minimize stress.
      5. Exercise 30 minutes per day. Being overweight is associated with a 5 times increased risk of chronic migraine.
      6. Keep well hydrated and drink 6-8 glasses of water per day.
    4. Initiate non-pharmacologic measures at the earliest onset of your headache.
      1. Rest and quiet in a cool, dark environment.
      2. Relax and reduce stress.
      3. Cold compress to head (place a dry washcloth to forehead, cover with a blue freezer packet and use a headband to press the freezer packet across the forehead and temples).
    5. Don't wait!! Take the maximum allowable dosage of prescribed medication at the very earliest sign of headache.
    6. Compliance: Take prescribed medication regularly as directed and at the first sign of a headache.
    7. Communicate: Call your physician when problems arise, especially if your headaches change, increase in frequency/severity, or become associated with neurological symptoms (weakness, numbness, slurred speech, etc.).
    8. Headache/pain management therapies: Consider various complementary methods, including yoga and meditation, home and natural remedies, behavioral therapy, acupuncture, acupressure, pressure points, psychological counseling, biofeedback, anti-nausea foods, massage therapy, and other modalities. Such measures may reduce the need for medications. Counseling for pain management, where patients learn to function and ignore/minimize their pain, seems to work very well.
    9. Recommend changing family's attention and focus away from patient's headaches. Instead, emphasize daily activities. If first question of day is “How are your headaches/Do you have a headache today?”, then patient will constantly think about headaches, thus making them worse. Goal is to re-direct attention away from headaches, toward daily activities and other distractions.