Migraine Treatment Options: A Doctor Q&A
Migraines are more common than people think and education is one of the more important tools for improving migraine care and management. Dr. David Watson, director of West Virginia University Headache Center and associate professor of neurology at West Virginia University School of Medicine, answered our questions about different treatment options for migraine and headache.
What is the most difficult thing about treating migraines?
I’m not sure there is one most difficult part of treating migraines. Some of the more significant difficulties include limited research funding and, therefore, limited advances in therapeutics, the stigma of migraine, and access to quality care for migraine suffers.
Currently, migraine research funding from federal sources such as the National Institutes of Health is sorely lacking. Despite the fact that migraine affects 36 million people in the United States and is a severely disabling condition with significant health care and societal costs, it receives extremely little from the NIH to support research that could lead to improved diagnosis and treatment.
The stigma of migraine affects people personally, socially, professionally and economically. This stigma carries over to those of us who specialize in treating migraine and other headache disorders. As the science of migraine has improved, this stigma has lessened, but we still fight an uphill battle, which is partly to blame for the lack of research funding.
With that many migraine sufferers in the United States, and 4 percent of the population with Chronic Daily Headache, there are simply more people who need quality headache care than are able to get it. This is not to say that everyone with migraine needs a headache specialist, but they do need a provider who is knowledgeable and interested in migraine to work with them. There are fewer than 400 certified headache specialists in the country. There is a severe deficiency of neurologists projected for the near future, and primary care providers are being pulled in multiple directions.
Can you explain the difference between preventative, abortive and rescue medications?
Preventative medications are usually taken daily for the purpose of reducing the total number of headaches or headache days that a person experiences. They may also help to improve the ability to stop a headache.
Abortive medications are taken at the onset of a headache, or as soon as possible, to make the pain and other symptoms resolve as quickly as possible. This would include such medication types as non-steroidal anti-inflammatories, triptans, ergotamines and others.
Rescue medications, in my book, are used when all else fails. Even in the best of treatment plans, sometimes a headache will break through. In these situations it may be necessary to have a back-up treatment. Often these are sedating, as sleep can be very helpful in stopping a headache. Categories may include anti-nausea medications, antihistamines, muscle relaxants, or anti-psychotics. Other options which could be considered rescue meds include steroids, injectable NSAIDs, and others. Every headache doctor has their own go-to rescue treatments.
Does treatment differ depending on the type of migraine?
There are many types of migraine, but a couple big categories are migraine without aura compared to migraine with aura, and chronic vs episodic migraine. Much of the treatment for these is the same. There is evidence that migraine with aura carries with it an increased risk of stroke, at least in younger patients, so more attention may be paid to other stroke risk factors. Some preventive medications tend to get used more for patients with aura than those without aura, but clear cut evidence for this is limited. Some patients with aura are able to take their abortive medication when the aura starts and stop it, while many others are not. It doesn’t hurt to try.
A common therapy for migraine is injections. How do injections help with migraines?
There are a variety of theories, some of which have merit. OnabotulinumtoxinA causes muscle weakness, but this does not seem to be a plausible explanation for how it works for migraine. It does have an effect on sensory input back into the brain, even though it does not cause numbness. To me, this seems like a logical explanation. The brain of a person with migraine is more easily triggered into the cascade of events which lead to migraine, and reducing inputs into this hyper-excitable brain may explain, at least in part, how OnabotulinumtoxinA is effective.
A quick caution about this treatment: It is more likely to be effective as part of a comprehensive approach to migraine management than as the only treatment. Patients and headache providers still need to work on trigger avoidance, lifestyle management, appropriate use of abortives, and may even need continued preventative medications. We can’t expect OnabotulinumtoxinA to do all the work.
Some foods may act as a trigger. In what ways should someone living with migraines change their eating habits?
I don’t like the idea of “migraine diets”. There are so many different foods or additives which can act as triggers that it is difficult to eliminate them all. Some food additives are common triggers, such as monosodium glutamate and nitrates, and these should be avoided or limited as much as possible. I recommend that patients keep a calendar and look for patterns. If they think that avocados trigger migraine, avoid them for a while and see what happens. If no change, add them back.
There are some general dietary rules that people with migraine should consider: Eating regular meals, drinking plenty of water, avoiding caffeinated drinks (especially anything later than lunchtime), and avoiding eating too close to bedtime (this can disrupt sleep due to need to urinate or lead to acid reflux).
Are there any other lifestyle changes you’d recommend?
Everybody needs to exercise. You don’t need to be a triathlete, but 20 to 30 minutes a day, three to four days per week is just plain good for you, no matter how bad your head hurts.
Sleep is another huge factor for anyone with chronic pain. Lack of sleep lowers pain thresholds. Having good sleep hygiene is key to getting good sleep. Again, limit or eliminate caffeine—definitely no caffeine after lunch. Even for those who insist it doesn’t affect their sleep, it does. Have a set time for going to bed. DO NOT watch TV, play video games, text message, email, etc., in bed. Get up at the same time in the morning. Try not to take naps during the day – if you feel sleepy, get up and work on that exercise part.
It’s often said that having a migraine journal is important. Why? How does this help with treatment?
If you see your doctor every four to six months, it is nearly impossible to accurately recall the frequency of your headaches or other details. Keeping a journal can improve your ability and your doctor’s ability to understand the frequency and nature of your headaches. Look for triggers. Look for patterns in the week or month, etc.
It can also help to detect small but important changes, such as increased or decreased frequency. If you start with 20 headaches per month and go down to 15 headaches per month that may suggest you are on the right path toward really getting your headaches under control. But 15 headaches a month is still an awful lot and without keeping a journal or calendar, you may not be able to notice the difference and, therefore, report that your treatment has not been effective.
Will there be any exciting new treatment options in the near future?
Boy, I hope so! A lot of promising work is being done, despite the aforementioned funding lack, and hopefully some of this work will be available in the near future. There are new categories of medications being developed which show promise. New ways of using old medications are being created, such as injectables, transdermal patches and oral inhalers. Nerve stimulation continues to move forward, with both surgical and nonsurgical options. While at present some of these options are used in research only, there is promise that at least some of these will become well proven, mainstream options in the relatively near future.
What is the most important thing someone living with migraines should know about their treatment options?
That they have options. There are so many different directions from which to attack migraine, it is nearly impossible to imagine that anyone could have actually done it all. If you feel that you are at a crossroads with your current provider, ask them if they can recommend someone else who might have a different insight. There is no headache doctor out there who is right for every headache sufferer. Keep searching, keep open to new ideas.