Although chronic migraine can’t be cured, the treatments available today can help decrease the frequency and severity of migraine attacks. “The condition can be properly treated, and the overwhelming majority of patients experience relief,” says Lawrence C. Newman, MD, professor of neurology and director of the headache division at NYU Langone Health in New York City.
To manage chronic migraine, you typically need a preventive medication, taken to stop attacks from occurring, and acute meds, taken to lessen symptoms after an attack starts. Finding a treatment regimen that works may require some trial and error.
Not all preventive medications work for everyone, and these drugs don’t stop all migraine episodes, but they can significantly cut down on the frequency of attacks and improve quality of life.
- OnabotulinumtoxinA (Botox): This treatment has been shown to reduce the number of hours of headache per month by about one-third—plus, you may be better able to perform your everyday activities while having headaches. A typical course of treatment involves getting injections every 12 weeks. It isn’t effective for everyone, but for many people, “it really works. Patients tell me it gives them their lives back,” says Greg Dussor, PhD, associate professor at the School of Behavioral and Brain Sciences at the University of Texas at Dallas. Neck pain and headache are rare side effects.
- Monoclonal antibodies: Several recently approved medications—eptinezumab (Vyepti), erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality)—work by blocking the activity of CGRP, a molecule involved in migraine. Research has shown that for many people, these drugs reduce the number of migraine days per month.
- Cardiovascular drugs: Some meds used to treat high blood pressure can also help prevent migraine attacks. These include beta-blockers and calcium channel blockers. Side effects for beta-blockers include dizziness, fatigue, depression, nausea, and insomnia. Calcium channel blockers can lead to weight gain, constipation, dizziness, or low blood pressure.
- Tricyclic antidepressants: Amitriptyline and nortriptyline may reduce the number of migraine attacks by changing levels of brain chemicals such as serotonin. They can induce dry mouth, tiredness, weight gain, and constipation, however.
- Antiseizure meds: Topiramate (Topamax) and divalproex sodium (Depakote) can also cut migraine frequency. Unfortunately, that benefit may be accompanied by weight change, dry mouth, sedation, memory issues, and decreased libido; both drugs have also been associated with fetal abnormalities.
Also called abortive meds, these tend to work best if taken as soon as you feel an episode coming on. But taking them too often can lead to medication overuse headaches. Ask your doctor about how often to take these.
- Triptans: These drugs stop the release of certain neurotransmitters, constrict blood vessels, and block pain pathways in the brain. They include sumatriptan (Alsuma, Imitrex, Sumavel, Zembrace), naratriptan (Amerge), zolmitriptan (Zomig), rizatriptan (Maxalt), almotriptan (Axert), frovatriptan (Frova), eletriptan (Relpax), and a combo of sumatriptan and naproxen sodium (Treximet). People with heart conditions or impaired liver function, as well as those who have had a stroke, shouldn’t take triptans.
- Lasmiditan (Reyvow): This drug for the acute treatment of migraine is the first in a new class of meds (ditans). It is like a triptan, except that it doesn’t constrict blood vessels. The makers of lasmiditan caution that a small number of users may experience serotonin syndrome (excessive levels of serotonin), driving impairment, or medication overuse headaches while on the drug.
- Gepants: The first medication in this class, ubrogepant (Ubrelvy), was approved by the FDA in 2019 for the acute treatment of migraine attacks. Rimegepant (Nurtec) received similar approval in 2020.
- Analgesics: Over-the-counter painkillers, including aspirin, naproxen, ibuprofen, and acetaminophen, may be taken alone or in combination with other meds to relieve mild to moderate headaches. Regular use can lead to gastrointestinal bleeding.
- Ergots and ergot derivatives: These drugs, which are often combined with caffeine (e.g., Migergot, Cafergot), narrow the blood vessels around the brain and prevent inflammation produced by neurotransmitters. Because they can cause or worsen nausea, they are sometimes taken with anti-nausea meds. Dihydroergotamine, available as an injection (DHE 45) or a nasal spray (Migranal), has fewer side effects. These drugs should not be used by people with heart conditions.
- Opioids: Narcotic pain medicines, such as oxycodone (e.g., Oxycontin) and hydrocodone (e.g., Vicodin), are sometimes used as a last resort for severe pain or in people who can’t take triptans or ergots. Opioids are highly addictive, so they’re used much less often than they used to be.
- Behavioral treatments: Cognitive behavioral therapy (CBT), biofeedback, and relaxation techniques can be useful adjunct treatments. They often address common migraine triggers, such as stress, sleep disturbances, anxiety, or depression. CBT is a common type of psychotherapy that helps people understand how their thoughts and behaviors affect their symptoms. Biofeedback involves hooking patients up to computers that provide feedback on physiological processes, such as muscle tension, and teaching them relaxation techniques.
- Neuromodulation: The Cefaly is a visor-like device that targets the trigeminal nerve. An FDA-approved treatment for migraine, it’s worn for 20 minutes once a day. The SpringTMS and a portable version, the sTMS mini, deliver mild magnetic impulses to the brain; approved for migraine with aura, these devices can stop a migraine that has started and prevent attacks.
More Treatment Options
Alternative therapies also offer migraine prevention and relief for some people:
- Supplements: Many supplements—magnesium, riboflavin, coenzyme Q10, and feverfew—have been touted to prevent migraine. “Supplements will not work that well for many people with chronic migraine,” says Dr. Dussor. “But they often have no side effects, and for that reason they’re worth trying.” Talk with your doctor first to make sure there aren’t any interactions between supplements you’re considering and meds you’re taking.
- Massage and Acupuncture: Acupuncture (the insertion of very fine needles into specific points on the body for pain relief) and massage may help, though little research has been done to show their effectiveness in people with chronic migraine.