Migraine headaches _ University of Maryland Medical Center.pdf

8/11/2019 Migraine headaches _ University of Maryland Medical Center.pdf

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Migraine headaches

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of migraine.

Highlights

Migraine Triggers

Migraines can be triggered by many everyday things. Different people respond to different triggers, so it is

important to track your migraine patterns to help you avoid things that set off your migraine attacks.

Common migraine triggers include:

Emotional stressIntense physical exertion

Abrupt weather changes

Bright or flickering lights

High altitude

Travel motion

Lack of sleep

Skipping meals

Odors

Certain foods and beverages (aged cheese, chocolate, red wine, beer, coffee, and many others)Food additives or preservatives (such as nitrates and monosodium glutamate)

Migraine Treatment Approaches

Migraines need a two-pronged approach: Treatment and prevention. Treatment uses medications that

provide quick pain relief when attacks occur. These drugs include pain relievers such as nonsteroidal anti-

inflammatory drugs (NSAIDs) or acetaminophen (Tylenol, generic), triptans such as sumatriptan (Imitrex,

generic), and ergotamine drugs.

Preventive strategies begin with non-drug approaches, including behavioral therapies and lifestyle changes. Ifheadache attacks continue to occur at least once a week, or if your attacks do not respond well to

treatment, your doctor may recommend you try preventive medication.

Migraine Prevention Guidelines

In 2012, the American Academy of Neurology (AAN) updated its guidelines for prevention of migraine in

adults. The main treatments recommended by the AAN for migraine prevention are:

Anti-seizure drugs [usually divalproex (Depakote, generic), valproate (Depacon, generic) or

topiramate (Topamax, generic)]Beta-blocker drugs [propranolol (Inderal, generic), timolol (Blocadren), or metoprolol (Lopressor,

generic)]

The triptan frovatriptan (Frova) for menstrual migraine


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The herbal remedy butterbur (Petasites hybridus)

Antidepressants [amitriptyline (Elavil, generic) or venlafaxine (Effexor, generic)] are also considered for

migraine prevention. OnabotulinumtoxinA (Botox) injections are approved for prevention of chronic

migraine.

Introduction

Migraine Headaches

Migraine headaches are a type of neurovascular headaches, a category that also includes cluster headaches.

Doctors believe that neurovascular headaches are caused by an interaction between blood vessel and nerve

abnormalities. Migraine headaches are the second most common type of primary headache after tension

headaches. A primary headache is a headache that is not caused by another disease or condition. [For more

information, seeIn-Depth Report#11: Headaches - tensionandReport#99: Headaches - cluster.]

Migraine headaches are characterized by throbbing disabling pain on one side of the head, which sometimesspreads to affect the entire head. In fact, migraine comes from the Greek word hemikrania, meaning half

of the head.

Migraines are classified as occurring either:

With aura (previously called classic migraine) or

Without aura (previously called common migraine)

Auras are sensory disturbances that occur before a migraine attack that can cause changes in vision, with or

without other neurologic symptoms. [For more information on auras, see Symptomssection of this report.]

Episodic and Chronic Migraine

Migraines typically occur as isolated episodic attacks, which can happen once a year or several times within

one week. In some cases, patients eventually experience on-going and chronic migraine (previously called

transformed migraine). Chronic migraines typically begin as episodic headaches when patients are in their

teens or 20s, and then increase in frequency over time. A headache is considered chronic when it occurs at

least half of the days in a month, and often on a daily or near-daily basis.

The majority of chronic migraines are caused by overuse of analgesic migraine medications, both

prescription pain reliever drugs and over-the-counter medications. Medication overuse headaches are also

called rebound headaches. Obesity and caffeine overuse are other factors that may increase the risk of

episodic migraine transforming to chronic migraine.

Chronic migraines can resemble tension-type headaches and it is sometimes difficult to differentiate between

them. Both types of headaches can co-exist. In addition to throbbing pain on one side of the head, chronic

migraine is marked by gastrointestinal symptoms such as nausea and vomiting. Many patients with chronic

migraine also suffer from depression.

Other Types of Migraine

Menstrual Migraines.Migraines are often tied to a woman's menstrual cycle, typically in the first days
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preceding or beginning menstruation. Estrogen and progesterone fluctuations may play a role. About half of

women with migraines report an association with menstruation. Compared to migraines that occur at other

times of the month, menstrual migraines tend to be more severe, last longer, and not have auras. Triptan

drugs can provide relief and may also help prevent these types of migraines.

Basilar Migraine.Considered a subtype of migraine with aura, this migraine starts in the basilar artery,

which forms at the base of the skull. It occurs mainly in young people. Symptoms may include vertigo (a

sensation of dizziness), ringing in the ears, slurred speech, unsteadiness, possibly loss of consciousness, andsevere headaches.

Abdominal Migraine. This migraine tends to occur in children who have a family history of migraine.

Periodic migraine attacks are accompanied by abdominal pain, and often nausea and vomiting.

Ophthalmoplegic Migraine.This very rare headache tends to occur in younger adults. The pain centers

around one eye and is usually less intense than in a standard migraine. It may be accompanied by vomiting,

double vision, a droopy eyelid, and paralysis of eye muscles. Attacks can last from hours to months. A

computed tomography (CT) or magnetic resonance imaging (MRI) scan may be needed to rule out bleeding

from an aneurysm (a weakened blood vessel) in the brain.

Retinal Migraine.Symptoms of retinal migraine are short-term blind spots or total blindness in one eye that

lasts less than an hour. A headache may precede or occur with the eye symptoms. Sometimes retinal

migraines develop without headache. Other eye and neurologic disorders must be ruled out.

Vestibular Migraine. These attacks produce episodic dizziness, which can develop alone or with headache

and other typical migraine symptoms. Ringing in the ears (tinnitus) and ear fullness are common.

Familial Hemiplegic Migraine.This is a very rare inherited genetic migraine disease. It can cause

temporary paralysis on one side of the body, vision problems, and vertigo. These symptoms occur about 10- 90 minutes before the headache.

Status Migrainosus.This is a serious and rare migraine. It is so severe and lasts so long that it requires

hospitalization.

Causes

The exact causes of migraine headaches are unknown. Doctors think that migraines may start with an

underlying central nervous system disorder. When triggered by various stimuli, this disorder may set off achain of neurologic and biochemical events, some of which subsequently affect the brain's blood vessel

(vascular) system.

There is certainly a strong genetic component to migraines. Several different genes are probably involved.

Many brain chemicals (neurotransmitters) and nerve pathway disrupters appear to play a role in causing

migraines. They include the neurotransmitter serotonin, magnesium deficiencies, and abnormalities in the

channels within cells that transport electrical ions such as calcium.

Migraine Triggers

Many types of events and conditions can alter conditions in the brain and trigger migraines. They include:


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Emotional stress

Physical exertion (such as intense exercise, lifting, or even bowel movements or sexual activity)

Abrupt weather changes

Bright or flickering lights

Odors

High altitude

Travel motion

Lack of sleepSkipping meals

Certain foods, and chemicals contained in them. More than 100 foods and beverages may potentially

trigger migraine headache. Caffeine is one such trigger. Caffeine withdrawal can also trigger migraines

in people who are accustomed to caffeine. Red wine and beer are also common triggers.

Preservatives and additives (such as nitrates, nitrites, and MSG) can also trigger attacks. Doctors

recommend that patients keep a headache diary to track the foods that trigger migraine.

Fluctuations of female hormones may trigger migraines in women.

Risk Factors

Gender

About 75% of all migraine sufferers are women. During childhood, boys and girls are equally affected. After

puberty, migraines are more common in girls. Migraine most commonly affects women between the ages of

20 - 45.

Fluctuations of female hormones, such as estrogen and progesterone, appear to increase the risk for

migraines and their severity in some women. About half of women with migraines report headachesassociated with their menstrual cycle. For some women, migraines also tend to be worse during the first

trimester of pregnancy, but improve during the last trimester.

Age

Migraine headaches typically affect people between the ages of 15 - 55. However, migraine also affects

about 5 - 10% of all children. Many children with migraine eventually stop having attacks when they reach

adulthood or transition to less severe tension-type headaches. Children with a family history of migraine may

be more likely to continue having migraines.

Family History

Migraines tend to run in families. About 70 - 80% of patients with migraine have a family history of the

condition.

Medical Conditions Associated with Migraines

People with migraine may have a history of depression, anxiety, stroke, epilepsy, irritable bowel syndrome,

or high blood pressure. These conditions do not necessarily increase the risk for migraine, but they areassociated with it.

Symptoms


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Postdrome Symptoms

After a migraine attack, there is usually a postdrome phase, in which patients may feel exhausted and

mentally foggy for a while.

Prognosis

For many people, migraines eventually go into remission and sometimes disappear completely, particularly

as they age. Estrogen decline after menopause may be responsible for remission in some older women.

Complications

Risk for Stroke and Heart Disease. Migraine or severe headache is a risk factor for stroke in both men

and women, especially before age 50. Research indicates that migraine may also increase the risk for other

types of heart problems.

Migraine with aura appears to carry a higher risk for stroke than migraine without aura, especially forwomen. Because of this, it is very important that women with migraine avoid other stroke risks such as

smoking and possibly birth control pills. Some studies suggest that people who have migraine with aura are

more likely than people without migraine to have cardiovascular risk factors (such as high cholesterol and

high blood pressure) that increase the risk for stroke. [For more information, seeIn-Depth Report#45:

Stroke.]

Emotional Disorders and Quality of Life. Migraines have a significant negative impact on quality of life,

family relations, and work productivity. Studies indicate that people with migraines have poorer social

interactions and emotional health than patients with many chronic medical illnesses, including asthma,

diabetes, and arthritis. Anxiety (particularly panic disorders) and major depression are also strongly

associated with migraines.

A National Headache Foundation-sponsored survey of migraine sufferers reported that:

90% of people with migraines could not function normally on the day of a migraine attack

80% experienced abnormal sensitivity to light and noise

75% experienced nausea and vomiting

30% required bed rest

25% missed at least 1 day of work due to migraine in past 3 months

Diagnosis

Anyone, including children, with recurring or persistent headaches should consult a doctor. There are no

blood tests or imaging techniques that can be used to diagnose migraine headaches. A diagnosis will be

made on the basis of medical history and physical exam, and, if necessary, tests may be necessary to rule

out other diseases or conditions that may be causing the headaches. It is important to choose a doctor who

is sensitive to the needs of headache sufferers and aware of the latest advances in treatment.

Diagnostic Criteria for Migraine

A diagnosis of migraine is usually made on the basis of repeated attacks (at least 5) that meet the following

criteria:
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Headache attacks that last 4 - 72 hours

Headache has at least two of the following characteristics: Location on one side of the head;

throbbing pain; moderate or severe pain intensity; pain worsened by normal physical activity (such as

walking or climbing stairs)

During the headache, the patient has one or both of the following characteristics: Nausea or vomiting;

extreme sensitivity to light or sound

The headache cannot be attributed to another disorder

Headache Diary

The patient should try to recall what seems to bring on the headache and anything that relieves it. Keeping a

headache diary is a useful way to identify triggers that bring on headaches, as well as to track the duration

and frequency of headache attacks. Some tips include:

Note all conditions, including any foods eaten, preceding an attack. Often two or more triggers

interact to produce a headache. For example, a combination of weather changes and fatigue can

make headaches more likely than the presence of just one of these events.

Keep a migraine record for at least three menstrual cycles. For women, this can help to confirm a

diagnosis of menstrual migraine.

Track medications. This is important for identifying possible medication-overuse (rebound) headache

or chronic (transformed) migraine.

Attempt to define the intensity of the headache using a number system, such as:

1 = Mild, barely noticeable

2 = Noticeable, but does not interfere with work/activities

3 = Distracts from work/activities

4 = Makes work/activities very difficult

5 = Incapacitating

Medical and Personal History

Tell your doctor any other conditions that might be associated with headache, including:

Any chronic or recent illness and their treatments

Any injuries, particularly head or back injuries

Any dietary changes

Any current medications or recent withdrawals from any drugs, including over-the-counter or natural

(herbal or dietary supplement) remedies

Any history of caffeine, alcohol, or drug abuse

Any serious stress, depression, or anxiety

The doctor will also need a general medical and family history of headaches or diseases, such as epilepsy,

that may increase their risk. Migraine tends to run in families.

Physical Examination


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The doctor will examine the head and neck and will usually perform a neurologic examination, which

includes a series of simple exercises to test strength, reflexes, coordination, and sensation. The doctor may

ask questions to test short-term memory and related aspects of mental function.

Differentiating Between Migraine and Other Types of Headaches

Differentiating Between Migraines and Tension Headaches. Migraine and tension-type headaches have

some similar characteristics, but also some important differences:

Migraine pain is throbbing, while tension-type headache pain is usually a steady ache

Migraine pain may affect only one side of the head while tension-type headache pain typically affects

both sides of the head

Migraine pain, but not tension-type pain, worsens with head movement

Migraine headaches, but not tension-type headaches, may be accompanied by nausea or vomiting,

sensitivity to light and sound, or aura

[For more information, seeIn-Depth Report#11: Tension-type headache.]

Differentiating Between Migraines and Sinus Headaches. Many primary headaches, including migraine,

are misdiagnosed as sinus headaches, causing patients to be treated inappropriately with antibiotics. Many

patients who think they have sinus headaches may actually have had a migraine. It is also possible for

patients to have migraines with sinus symptoms such as congestion and facial pressure.

Sinus headaches occur in the front of the face, with pain or pressure around the eyes, across the cheeks, or

over the forehead. They are usually accompanied by fever, runny nose or congestion, and fatigue. In sinus

headaches, the nasal discharge is thick green or yellow. Nasal discharge in migraines is clear and watery.

A real sinus headache is a sign of an acute sinus infection, which responds to treatment with decongestants

and may sometimes require antibiotics. If sinus headaches seem to recur, the patient is likely experiencing

migraines.

Imaging Tests

The doctor may order a computed tomography (CT) scan or magnetic resonance imaging (MRI) test of the

head to check for brain abnormalities that may be causing the headaches. Imaging tests of the brain may be

recommended if the results of the history and physical examination suggest neurologic problems such as:

Changes in vision

Muscle weakness

Fever

Stiff neck

Changes in the way someone walks

Changes in someone's mental status (disorientation)

Imaging tests may also be recommended for patients with headache:

That wakes them at night

A sudden or severe headache, or a headache that is the worst headache of someone's life

New headaches in adults over 50 years, especially in the elderly. In this age group, it is particularly

important to first rule out age-related disorders including stroke, low blood sugar (hypoglycemia),
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accumulation of fluid within the brain (hydrocephalus), and head injuries (usually from falls).

Worsening headache or headaches that do not respond to routine treatment.

A CT (computed tomography) scan is a much more sensitive imaging technique than x-ray, allowing high

definition of not only the bony structures but also the soft tissues. Clear images of organs and structures,

such as the brain, muscles, joints, veins and arteries, as well as of tumors and hemorrhages, may be obtained

with or without the injection of contrasting dye.

Symptoms that Could Indicate a Serious Underlying Condition

Headaches indicating a serious underlying problem, such as cerebrovascular disorder or malignant

hypertension, are uncommon. (It should be emphasized that a headache without other neurologic symptoms

is not a common symptom of a brain tumor.) People with existing chronic headaches, however, might miss a

more serious condition by believing it to be one of their usual headaches. Such patients should call a doctor

promptly if the quality of a headache or accompanying symptoms has changed. Everyone should call a

doctor for any of the following symptoms:

Sudden, severe headache that persists or increases in intensity over the following hours, sometimes

accompanied by nausea, vomiting, or altered mental states (possible hemorrhagic stroke)Sudden, very severe headache, worse than any headache ever experienced (possible indication of

hemorrhage or a ruptured aneurysm)

Chronic or severe headaches that begin after age 50

Headaches accompanied by other symptoms, such as memory loss, confusion, loss of balance,

changes in speech or vision, or loss of strength in or numbness or tingling in arms or legs (possibility of

stroke or brain tumor)

Headaches after head injury, especially if drowsiness or nausea are present (possibility of

hemorrhage)

Headaches accompanied by fever, stiff neck, nausea and vomiting (possibility of spinal meningitis)

Headaches that increase with coughing or straining (possibility of brain swelling).

A throbbing pain around or behind the eyes or in the forehead accompanied by redness in the eye

and perceptions of halos or rings around lights (possibility of acute glaucoma)

A one-sided headache in the temple in elderly people; the artery in the temple is firm and knotty and


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has no pulse; scalp is tender (possibility of temporal arteritis, which can cause blindness or even

stroke if not treated)

Sudden onset and then persistent, throbbing pain around the eye possibly spreading to the ear or

neck unrelieved by pain medication (possibility of blood clot in one of the sinus veins of the brain)

Treatment Approaches

Migraine treatment involves both treating acute attacks when they occur and developing preventive

strategies for reducing the frequency and severity of attacks.

Treating Migraine Attacks

Many effective headache remedies are available for treating a migraine attack. Still, many patients are

treated with unapproved drugs, including opoids and barbiturates that can be potentially addictive or

dangerous.

The main types of medications for treating a migraine attack are:

Pain relievers [usually nonprescription nonsteroidal anti-inflammatory drugs (NSAIDs) or

acetaminophen]

Ergotamines

Triptans

It is best to treat a migraine attack as soon as symptoms first occur. Doctors generally recommend:

Start with nonprescription pain relievers for mild-to-moderate attacks. If migraine pain is severe, a

prescription version of an NSAID may be recommended.A triptan is generally the next drug of choice.

Ergotamine drugs tend to be less effective than triptans but are helpful for some patients.

Depending on the severity of the attacks, and accompanying symptoms, the doctor may recommend

taking a triptan or ergotamine drug in tablet, injection, or suppository form. The doctor may also

prescribe specific medications for treating symptoms such as nausea.

Try to guard against medication overuse, which can cause a rebound effect. Nearly all pain relief drugs used

for migraine can cause rebound headache, and patients should not take any the drugs more than 9 days per

month. If you find that you need to use acute migraine treatment more frequently, talk to your doctor about

preventive medications.

Preventing Migraine Attacks

Preventive strategies for migraine include both drug treatment and behavioral therapy or lifestyle

adjustments.

Patients should consider using preventive migraine drugs if they have:

Migraines that are not helped by acute treatment drugsFrequent attacks (more than once per week)

Side effects from acute treatment drugs or contraindications to taking them

The main preventive drug treatments for migraine are:


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Beta-blocker drugs [usually propranolol (Inderal, generic) or timolol (Blocadren)]

Anti-seizure drugs [usually divalproex (Depakote, generic), valproate (Depacon, generic) or

topiramate (Topamax, generic)]

Tricyclic antidepressants [usually amitriptyline (Elavil, generic)] or the dual inhibitor antidepressant

venlafaxine (Effexor, generic)

The triptan frovatriptan (Frova) for menstruation-associated migraine

OnabotulinumtoxinA (Botox) injection is also approved for prevention of migraine but it appears to workbest for chronic (not episodic) migraine.

Butterbur (Petasites hybridus) is an herbal remedy that may be effective for migraine prevention. It is

recommended by the American Academy of Neurology.

A preventive medication strategy needs to be carefully tailored to an individual patient, taking into account

the patient's medical history and co-existing medical conditions. These drugs can have serious side effects.

A preventive medication is usually started at a low dose, and then gradually increased. It may take 2 - 3

months for a drug to achieve its full effect. Preventive treatment may be needed for 6 - 12 months or longer.Most patients take preventive medications on a daily basis, but some patients may use these drugs

intermittently (for example, for preventing menstrual migraine).

Patients can also help prevent migraines by identifying and avoiding potential triggers, such as specific foods.

Relaxation therapy and stress reduction techniques may also help. (SeeLifestylesection in this report.)

Treatment Approaches for Children

Migraine Treatment for Children.Most children with migraines may need only mild pain relievers and

home remedies (such as ginger tea) to treat their headaches. The American Academy of Neurology's

practice guidelines for children and adolescents recommend the following drug treatments:

For children age 6 years and older, ibuprofen (Advil, generic) is recommended. Acetaminophen

(Tylenol, generic) may also be effective. Acetaminophen works faster than ibuprofen, but the effects

of ibuprofen last longer.

For adolescents age 12 years and older, sumaptriptan (Imitrex) nasal spray is recommended.

Migraine Prevention for Children.Non-medicinal methods, including biofeedback and muscle relaxation

techniques, may be helpful. If these methods fail, then preventive drugs may be used, although evidence isweak on the effectiveness of standard migraine preventive drugs in children.

Withdrawing from Medications

If medication overuse causes rebound migraines to develop, the patient cannot recover without stopping the

drugs. (If caffeine is the culprit, a person may need only to reduce coffee or tea drinking to a reasonable

level, not necessarily stop drinking it altogether.) The patient can usually stop abruptly or gradually. The

patient should expect the following:

Most headache drugs can be stopped abruptly, but the patient should talk to their doctor first.

Certain non-headache medications, such as anti-anxiety drugs or beta-blockers, require gradual

withdrawal under medical supervision.

If the patient chooses to taper off standard headache medications, withdrawal should be completed


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within 3 days.

The patient may take other pain medicines during the first days. Examples of drugs that may be used

include dihydroergotamine (with or without metoclopramide), NSAIDs (in mild cases),

corticosteroids, or valproate.

Patients should expect their headaches to get worse after they stop taking their medications, no

matter which method they use. Most people feel better within 2 weeks, although headache symptoms

can persist up to 16 weeks (and in rare cases even longer).

If the symptoms do not respond to treatment and cause severe nausea and vomiting, the patient mayneed to be hospitalized.

Medications for Treating Migraine Attacks

Many different medications are used to treat migraines. Some migraines respond to non-prescription pain

relievers such as ibuprofen, acetaminophen, naproxen, or aspirin. Among prescription drugs, triptans and

ergotamine are the only types of medications approved by the Food and Drug Administration (FDA) for

migraine treatment.

Other types of drugs, including opioids and barbiturates, are sometimes prescribed off-label for migraine

treatment. Opioids and barbiturates have not been approved by the FDA for migraine relief, and they can

be addictive.

All FDA-approved migraine treatments are approved only for adults. No migraine products have officially

been approved for use in children.

Pain Relievers

Some patients with mild migraines respond well to over-the-counter (OTC) painkillers, particularly if they

take a full dose of the medicine at the very first sign of an attack. OTC pain relievers, also called analgesics,

include:

Nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin, generic), naproxen (Aleve,

generic), and aspirin. Products marketed as Advil Migraine or Motrin Migraine Pain are simply

ibuprofen in a liquid-filled capsule.

Acetaminophen (Tylenol, generic). Excedrin Migraine contains a combination of acetaminophen,

aspirin, and caffeine.

There are also prescription-only NSAIDs such as diclofenac (Cataflam, generic).

NSAID Side Effects. High dosages and long-term use of NSAIDs can increase the risk for heart attack,

stroke, kidney problems, and stomach bleeding. Aspirin does not increase the risk for heart problems, but it

can cause other NSAID-related side effects. Frequent or daily use of NSAIDs may worsen migraines and

lead to the development of medication overuse headache.

Triptans

Triptans (also referred to as serotonin agonists) were the first drugs specifically developed for migrainetreatment. They are the most important migraine drugs currently available. They help maintain serotonin

levels in the brain. Serotonin is one of the major brain chemicals involved in migraines.


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Triptans are recommended as first-line drugs for adult patients with moderate-to-severe migraines when

NSAIDs are not effective. Triptans have the following benefits:

They are effective for most patients with migraine, as well as patients with combination tension and

migraine headaches.

They do not have the sedative effect of other migraine drugs.

Withdrawal after overuse appears to be shorter and less severe than with other migraine medications

Sumatriptan.Sumatriptan (Imitrex, generic) has the longest track record and is the most studied of all

triptans. It is available as a fast-dissolving pill, nasal spray, or injection. Injected sumatriptan works the

fastest of all the triptans and is the most effective, but it can cause pain at the injection site. The nasal spray

form bypasses the stomach and is absorbed more quickly than the oral form. Some patients report relief as

soon as 15 minutes after administration. The spray tends to work less well when a person has nasal

congestion from cold or allergy. It may also leave a bad taste. Sumatriptan is effective for many patients, but

for some people headache recurs within 24 hours after taking the drug.

Other Triptans. Newer triptans include almotriptan (Axert), zolmitriptan (Zomig), naratriptan (Amerge,

generic), rizatriptan (Maxalt), frovatriptan (Frova), and eletriptan (Relpax). Treximet combines in one pillboth sumatriptan and the anti-inflammatory pain reliever naproxen (Aleve, generic). Frovatriptan is also

recommended for prevention of menstrual migraine, and naratriptan and zolmitriptan may possibly be

effective.

Although triptans, (like all migraine medications), are approved only for adults, researchers are investigating

zolmitriptan for treating migraines in adolescents.

Side Effects. Side effects of triptans may include:

Tingling and numbness in the toesSensations of warmth

Discomfort in the ear, nose, and throat

Nausea

Drowsiness

Dizziness

Muscle weakness

Heaviness or pain in the chest (especially with sumatriptan)

Rapid heart rate

Complications of Triptans. The following are potentially serious problems.

Complications of heart and circulation. Triptans narrow (constrict) blood vessels. Because of this

effect, spasms in the blood vessels may occur and cause serious side effects, including stroke and

heart attack. Such events are rare, but patients with an existing history or risk factors for these

conditions should generally avoid triptans.

Serotonin syndrome. Serotonin syndrome is a life-threatening condition that occurs from an excess of

the brain chemical serotonin. Triptan drugs used to treat migraine, as well as certain types of

antidepressant medications, can increase serotonin levels. These antidepressant drugs include

serotonin reuptake inhibitors (SSRIs) -- such as fluoxetine (Prozac, generic), paroxetine (Paxil,generic), and sertraline (Zoloft, generic) -- and selective serotonin/norepinephrine reuptake inhibitors

(SNRIs), such as duloxetine (Cymbalta) and venlafaxine (Effexor, generic). It is very important that

patients not combine a triptan drug with a SSRI or SNRI drug. Serotonin syndrome is most likely to


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occur when starting or increasing the dose of a triptan or antidepressant drug. Symptoms include

restlessness, hallucinations, rapid heartbeat, tremors, increased body temperature, diarrhea, nausea,

and vomiting. You should seek immediate medical care if you have these symptoms.

The following people should avoid triptans or take them with caution and only under a doctor's supervision:

Anyone with a history or any risk factors for stroke, uncontrolled diabetes, high blood pressure, or

heart disease.People taking antidepressants that increase serotonin levels.

Children and adolescents. They may be safe, but controlled studies are needed to confirm this.

(Triptans should not, in any case, be the first-line treatment for children.)

People with basilar or hemiplegic migraines. (Triptans are not indicated for these migraineurs.)

There is no evidence to date of any higher risk for birth defects in pregnant women who take triptans.

Still, women should be cautious about taking any medications during pregnancy and discuss any

possible adverse effects with their doctors.

Ergotamine (Ergot)

Drugs containing ergotamine (commonly called ergots) constrict smooth muscles, including those in blood

vessels, and are useful for migraine. They were the first anti-migraine drugs available. Ergotamine is available

by prescription in the following preparations:

Dihydroergotamine (DHE) is an ergot derivative. It is administered as a nasal spray form (Migranal)

or by injection, which can be performed at home.

Ergotamine is available as tablets taken by mouth, tablets taken under the tongue (sublingual), and

rectal suppositories. Some of the tablet forms of ergotamine contain caffeine.

Ergotamine's role since the introduction of triptans is now less certain. Only the rectal forms of ergotamine

are superior to rectal triptans. Injected, oral, and nasal-spray forms are all inferior to the triptans.

Ergotamine may still be helpful for patients with status migrainous or those with frequent recurring

headaches.

Side Effects. Side effects of ergotamine include:

Nausea

Dizziness

Tingling sensationsMuscle cramps

Chest or abdominal pain

The following are potentially serious problems:

Toxicity. Ergotamine is toxic at high levels.

Adverse effects on blood vessels. Ergot can cause persistent blood vessel contractions, which may

pose a danger for people with heart disease or risk factors for heart attack or stroke.

Internal scarring (fibrosis). Scarring can occur in the areas around the lungs, heart, or kidneys. It is

often reversible if the drug is stopped.

The following patients should avoid ergots:

Pregnant women. Ergots can cause miscarriage.


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People over age 60.

Patients with serious, chronic health problems, particularly those with heart and circulation conditions.

Ergotamine can interact with other medications, such as antifungal drugs and some antibiotics. All

ergotamine products approved by the FDA contain a "black box" warning in the prescription label

explaining these drug interactions. The five FDA-approved ergotamine products are:

Migergot suppository (marketed by G and W Labs)Ergotamine Tartrate and Caffeine tablets (marketed by Mikart and West Ward)

Cafergot tablets (marketed by Sandoz)

Ergomar sublingual tablets (marketed by Rosedale Therapeutics)

Opioids

If migraine pain is very severe and does not respond to other drugs, doctors may try painkillers containing

opioids. Opioid drugs include morphine, codeine, meperidine (Demerol, generic), and oxycodone

(Oxycontin)]. Butorphanol is an opioid in nasal spray form that may be useful as a rescue treatment when

others fail.

Opioids are not approved for migraine treatment and should not be used as first-line therapy. Nevertheless,

many opioid products are prescribed to patients with migraine, sometimes with dangerous results. For

example, following reports of several drug-related deaths, the FDA warned that the cancer pain pill fentanyl

(Fentora, generic) should not be used to treat patients with migraine or others conditions for which the drug

is not specifically approved.

Side Effects. Side effects for all opioids include drowsiness, impaired judgment, nausea, and constipation.

There is a risk for addiction, and these drugs can become ineffective with long-term use for chronicmigraines. Doctors should not prescribe opioids to patients at risk for drug abuse, including those with

personality or psychiatric disorders.

Drugs Used for Nausea and Vomiting

Metoclopramide (Reglan, generic) is used in combination with other drugs to treat the nausea and vomiting

that sometimes occur either as a medication side effect or migraine symptom. Metoclopramide and other

anti-nausea drugs may help the intestine better absorb migraine medications.

Medications for Preventing Migraine Attacks

The FDAs approved drugs for prevention of migraine are:

Propanolol (Inderal, generic)

Timolol (Blocadren)

Divalproex sodium (Depakote, generic)

Valproate sodium (Depacon, generic)

Valproic acid (Stavzor, Depakene, generic)

Topiramate (Topamax, generic)OnabotulinumtoxinA (Botox)

Propanolol and timolol are beta-blocker drugs. Divalproex, valproate, valproic acid, and topiramate are


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anti-seizure drugs. Many other drugs are also being used or investigated for preventing migraines.

Beta Blockers

Beta blockers are usually prescribed to reduce high blood pressure. Some beta blockers are also useful in

reducing the frequency of migraine attacks and their severity when they occur. Propranolol (Inderal, generic)

and timolol (Blocadren) are approved specifically for prevention of migraine. Metoprolol (Lopressor,

generic) is also recommended and atenolol (Tenormin, generic), and nadolol (Corgard, generic) may also beconsidered for migraine prevention.

Side Effects. Side effects may include:

Fatigue and lethargy are common.

Some people experience vivid dreams and nightmares, depression, and memory loss.

Dizziness and lightheadedness may occur upon standing.

Exercise capacity may be reduced.

Other side effects may include cold extremities (legs, arms, feet, hands), asthma, decreased heart

function, gastrointestinal problems, and sexual dysfunction.

If side effects occur, the patient should call a doctor, but it is extremely important not to stop the drug

abruptly. Some evidence suggests that people with migraines who have had a stroke should avoid beta

blockers.

Anti-Seizure Drugs

Anti-seizure drugs, also called anticonvulsant drugs, are commonly used for treating epilepsy and bipolar

disorder. Divalproex sodium (Depakote, Depakote ER, generic), valproic acid (Stavzor, Depakene,generic) and topiramate (Topamax, generic) are the only anti-seizure drugs that are approved for migraine

prevention.

Side Effects. Anti-seizure medication side effects vary by drug but may include:

Nausea and vomiting

Diarrhea

Cramps

Tingling sensation in arms and legs

Hair lossDizziness

Sleepiness

Blurred vision

Weight gain (or with topiramate, weight loss)

Valproate and divalproex can cause serious side effects of inflammation of the pancreas (pancreatitis)

and damage to the liver

Divalproex sodium, valproic acid, and topiramate can increase the risk for birth defects, particularly cleft

palate and cognitive development. These drugs should not be used during the first trimester of pregnancy.Women who are of child-bearing age and considering pregnancy should discuss the safety of these drugs

with their doctors and consider other types of migraine preventive medication.

All anti-seizure drugs can increase the risks of suicidal thoughts and behavior (suicidality). The highest risk of


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suicide can occur as soon as 1 week after beginning drug treatment and can continue for at least 24 weeks.

Patients who take these drugs should be monitored for signs of depression, changes in behavior, or

suicidality. [For more information, seeIn-Depth Report#44: Epilepsy.]

Tricyclics and Other Antidepressants

Amitriptyline (Elavil, Endep, generic), a tricyclic antidepressant drug, has been used for many years as a

first-line treatment for migraine prevention. It may work best for patients who also have depression orinsomnia. Tricyclics can have significant side effects, including disturbances in heart rhythms, and can be fatal

in overdose. Although other tricyclic antidepressants may have fewer side effects than amitritpyline, they do

not appear to be particularly effective for migraine prevention.

Venlafaxine (Effexor, generic) is another antidepressant recommended for migraine prevention. It is a

serotonin norepinephrine reuptake inhibitor (SNRI). Serotonin-reuptake inhibitors (SSRIs), such as

fluoxetine (Prozac, generic), do not appear to be effective for migraine prevention.

Botox Injections

OnabtulinumtoxinA (Botox) is now approved for preventing chronic migraine in adults. Botox is given by

multiple injections to the head and neck area about every 12 weeks. These injections may help to dull future

headache symptoms. Botox appears to work best for chronic migraines. It has not been shown to work for

migraines that occur less frequently than 14 days a month or for other types of headaches (such as tension

headaches). The most common side effects are neck pain and headache.

Other Treatments for Preventing Migraines

Other types of medications and treatments are being used or investigated for prevention of migraines.

Triptans. Frovatriptan is effective for prevention of menstrual migraines. Naratriptan (Amerge, generic) and

zolmitriptan (Zomig) may also be helpful.

NSAIDs. Certain over-the-counter and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) may be

helpful for migraine prevention. They include naproxen (Aleve, generic), ibuprofen (Aleve, Motrin, generic),

fenoprofen (Nalpron), and ketoprofen (Nexcede, generic). However, daily use of NSAIDs can cause

stomach problems and may also lead to a condition called medication overuse headache.

ACE Inhibitors. Commonly used for treating high blood pressure, angiotensin converting enzyme (ACE)

inhibitors such as lisinopril (Prinivil, generic) block the production of the protein angiotensin, which constricts

blood vessels and may be involved in migraine.

Angiotensin-Receptor Blockers.Angiotensin-receptor blockers (ARBs), such as candesartan (Atacand),

are another type of high blood pressure medications being studied for migraine prevention.

Histamine.Subcutaneous (under the skin) injections of histamine may be helpful for migraine prevention.

Neurostimulation Devices. Researchers are investigating a transcranial magnetic stimulation (TMS) device

to help stop migraines before they occur. The hair dryer-size device is held to the back of the head and

delivers quick magnetic pulses. The device is used when a patient experiences the first signs of a migraine.

Other types of nerve stimulation devices are also under investigation.
http://umm.edu/health/medical/reports/articles/epilepsy


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Nasal Devices. New types of nasal sprays and powders are being researched. Some of them use capsaicin,

the chemical found in cayenne peppers, to help relieve pain.

Herbs and Dietary Supplements. Certain herbs and dietary supplements may be helpful for migraine

prevention. SeeNon-Drug Treatments and Lifestyle Changessection of this report.

Non-Drug Treatments and Lifestyle Changes

There are several ways to prevent migraine attacks. You should first try a healthy diet, the right amount of

sleep, and non-drug approaches (such as biofeedback) for prevention.

Behavioral Treatments

Behavioral techniques that reduce stress and empower the patient may help some people with migraines.

They generally include:

Biofeedback therapyRelaxation techniques

Cognitive-behavioral therapy

Behavioral methods may help counteract the tendency for muscle contraction and uneven blood flow

associated with some headaches. They may be particularly beneficial for children, adolescents, pregnant and

nursing women, and anyone who cannot take most migraine medications. Studies generally find that these

techniques work best when used in combination with medications.

Biofeedback.Many studies have demonstrated that biofeedback is effective for reducing migraine headache

frequency. Biofeedback training teaches the patient to monitor and modify physical responses, such asmuscle tension, using special instruments for feedback.

Relaxation Therapy. Relaxation therapy techniques include relaxation response, progressive muscle

relaxation, visualization, and deep breathing. Muscle relaxation techniques are simple and easy to learn, and

can be effective. Some patients may also find that relaxation techniques combined with applying a cold

compress to the forehead may help provide some pain relief during attacks. Some commercially available

products use a pad containing a gel that cools the skin for several hours.

Cognitive Behavioral Therapy.Cognitive-behavioral therapy (CBT) teaches patients how to recognize

and cope with stressors in their life. It can help patients understand how their thoughts and behavior patterns

may affect their symptoms, and how to change the way the body responds to anticipated pain. CBT may be

included with stress management techniques. Research indicates that CBT is most effective when combined

with relaxation training or biofeedback.

Acupuncture

Acupuncture is a Chinese medicine technique that uses thin needles to stimulate specific points aligned with

energy pathways in the body. Studies have showed mixed results on the benefits of acupuncture for

preventing migraine.

Lifestyle Changes


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Making a few minor changes in your lifestyle can make your migraines more bearable. Improving sleep

habits is important for everyone, and especially those with headaches. What you eat also has a huge impact

on migraines, so dietary changes can be extremely beneficial, too.

Avoid Food Triggers.Avoiding foods that trigger migraine is an important preventive measure. Common

food triggers include monosodium glutamate (MSG), processed lunch meats that contain nitrates, dried fruits

that contain sulfites, aged cheese, alcohol and red wine, chocolate, and caffeine. However, peoples

responses to triggers differ. Keeping a headache diary that tracks diet and headache onset can help identifyindividual food triggers.

Eat Regularly.Eating regularly is important to prevent low blood sugar. People with migraines who fast

periodically for religious reasons might consider taking preventive medications.

Stay Physically Active. Exercise is certainly helpful for relieving stress. An analysis of several studies

reported that aerobic exercise in particular might help prevent migraines. It is important, however, to warm

up gradually before beginning a session, since sudden, vigorous exercise might actually precipitate or

aggravate a migraine attack.

Limit Estrogen-Containing Medications. Medications that contain estrogen, such as oral contraceptives

and hormone replacement therapy, may trigger migraines or make them worse. Talk to your doctor about

whether you should stop taking these types of medications or reduce the dosage.

Herbs and Supplements

Manufacturers of herbal remedies and dietary supplements do not need Food and Drug Administration

approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and

therefore have the potential to produce side effects that may be harmful. There have been several reportedcases of serious and even lethal side effects from herbal products. Patients should always check with their

doctors before using any herbal remedies or dietary supplements.

In 2012, the American Academy of Neurology (AAN) updated its guidelines on migraine prevention to

include complementary treatments. Based on reviews of clinical studies, the AAN recommends:

Butterbur (Petasites hybridus).Butterbur is a traditional herbal remedy used for many types of

ailments, including migraine. The AAN considers butterbur effective and recommends it be offered

for migraine prevention. Butterbur was the only non-drug treatment ranked by the AAN as having the

highest proof of evidence (Level A) for effectiveness. Butterbur may cause an allergic reaction inpeople who are sensitive to ragweed and related plants.

Feverfew.Feverfew is another well-studied herbal remedy for headaches. The AAN ranks feverfew

as probably effective (Level B evidence) and recommends that it be considered for migraine

prevention. Pregnant women should not take this herb as it may potentially harm the fetus.

Riboflavin (Vitamin B2) and Magnesium. Riboflavin and magnesium are the two vitamin and

mineral supplments ranked by the AAN as probably effective. Vitamin B2 is generally safe,

although some people taking high doses develop diarrhea. Magnesium helps relax blood vessels.

Some studies have reported a higher rate of magnesium deficiencies in some patients with migraine..

Although not specifically recommended by the AAN, other herbal and dietary supplements associated with

migraine prevention include:

Fish Oil. Some studies suggest that omega-3 fatty acids, which are found in fish oil, have anti-


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inflammatory and nerve protecting actions. These fatty acids can be found in oily fish, such as salmon,

mackerel, or sardines. They can also be obtained in supplements of specific omega-3 compounds

(DHA-EPA).

Ginger.In general, herbal medicines should never be used by children or pregnant or nursing women

without medical counsel. One exception may be ginger, which has no side effects and can be eaten or

taken as a tea in powder or fresh form, as long as quantities are not excessive. Some people have

reported less pain and frequency of migraines while taking ginger, and children can take it without

danger. Ginger is also a popular home remedy for relieving nausea.

Resources

www.headaches.org-- National Headache Foundation

www.achenet.org-- American Headache Society

www.aan.com-- American Academy of Neurology

www.ninds.nih.gov-- National Institute of Neurological Disorders and Stroke

www.clinicaltrials.gov-- Find clinical trials

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Gilmore B, Michael M. Treatment of acute migraine headache.Am Fam Physician. 2011 Feb1;83(3):271-80.

Goadsby PJ. Pathophysiology of migraine.Neurol Clin. 2009 May;27(2):335-60.

Holland S, Silberstein SD, Freitag F, Dodick DW, Argoff C, Ashman E; Quality Standards Subcommittee

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Lewis D, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein S, et al. Practice parameter:

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Version Info

Last Reviewed on 12/17/2012

Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School;

Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical

Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare

Commission (www.urac.org). URAC's accreditation program is an independent audit to verify thatA.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve

this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial

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