Let’s Talk About Migraine Treatment
Every migraine patient is different and so is every treatment plan. We review your options so you can get relief.by Linda Rodgers Health Writer
The migraine you had last time is not necessarily the one you’ll have again. Your new attack might start with you seeing zigzags, getting tunnel vision, or feeling a tingle in your hands before a throbbing painful headache starts 20 minutes later. Or you just might get a headache that’s bad enough to send you to bed with the shades drawn.*
Our Pro Panel
We went to some of the nation’s top experts in migraines to bring you the most up-to-date information possible.
Marius Birlea, M.D.
Assistant Professor of Neurology; Director, Headache Fellowship
University of Colorado Denver School of Medicine
Joel R. Saper, M.D.
Michigan Headache & Neurological Institute
Ann Arbor, MI
Stewart J. Tepper, M.D.
Professor of Neurology
Geisel School of Medicine, Dartmouth
The answer (like all answers): It depends. There are newer drugs that have just been approved that target specific brain chemicals thought to be responsible for producing migraine pain. These drugs come in the form of monthly injections, but in order to get an Rx, you have to have tried other medications that ultimately failed for you. There are also at-home devices that have fewer side effects and are good for people who don’t want to take medications (or whose meds haven’t worked).
Yes—and those range from brain-stimulating devices like the Nerivio patch/app for people with episodic migraines to magnesium supplements for those who have migraines with auras. You could also try acupuncture, yoga, mindfulness meditation, and even cognitive behavioral therapy. All of those have some science-based evidence to show that they can cut headache pain and frequency.
Yes, but this treatment is only approved for people who suffer from chronic migraines. You need to get a series of injections every three months or so.
If you have several migraines a month, especially if they are debilitating, you might want to consult a doctor about adding a preventative treatment to your pain relief regimen. That could be as simple as taking extra supplements (like melatonin that can help you sleep better and block the pain-producing CGRP), or getting an Rx for injections that can cut the number of migraine days or a brain-stimulating device that works to prevent migraines as well cut the pain during an attack.
*And just as all attacks can differ, so can every treatment plan. Your doctor will go over your migraine history and offer recommendations based on the type of migraines you have, how many attacks you have a month, recent research, and their own experience. There are many more options now than even just a year or two ago—more preventative treatments and more meds to stop attacks, and even some alternative methods that are backed by science. This overview of potential choices can help you get a clearer picture of what you can do to stop the pain.
What Are Migraines Again?
Think of migraines as a brain disease. Thanks to a strong family history (your mom or dad probably had attacks, too), you’ve inherited a brain that’s super-sensitive to certain triggers that set off a cascade of changes in different parts of the brain.
While experts don’t know for sure the exact interplay between the neural pathways and chemicals that produces the symptoms of migraines, they think that the hypothalamus, the part of the brain that regulates many of the body’s functions, and the brain stem are involved. At the beginning of an attack, these areas start to communicate with one another in an abnormal way. As the nerves in these areas start to fire more and more, they release chemicals that cause inflammation and dilate the blood vessels, producing pain.
These attacks happen at least once or twice a month for the 39 million people in the U.S. who have migraines. About 10% have attacks several times a month. Another 8% have them more than 15 times a month. Three times as many women have migraines than men. But even little kids can have them.
What’s the Best Treatment for Migraines?
Basically, there are two types of treatment—the type that prevent attacks, or at least lower the number and intensity (known as preventative); and treatments that you take during an attack (known as acute). These include oral meds as well as injections and non-drug devices. There are also complementary treatments that include supplements and lifestyle changes that help keep triggers at bay.
Most of these, except for one exception, work for every kind of migraine patient. A doctor will diagnose you with episodic migraines if you get fewer than 15 attacks per month. Chronic migraine patients are those who have more than 15 attacks. Sadly, both types of migraine patients don’t get the help they need. When they surveyed people with migraines in 2016, researchers discovered that fewer than half (40%) were seeing a provider for their migraines—and only a quarter of those folks had gotten an accurate diagnosis with the right treatment. The American Migraine Prevalence and Prevention Study, which also surveyed those with migraines, found that while 98% took medications during an attack, only one in five took drugs that could prevent migraines—and the majority of those discontinued using those preventative treatments because of side effects.
Doctors found that for many people with migraines the best treatment involves preventative remedies along with medications that you can take during an attack. And luckily, in the past two years, a number of new drugs that target specific pain receptors have become available to migraine sufferers. There are also non-drug devices that are also new to the market. Your best bet for the right treatment is to go to a dedicated headache specialist or clinic to find relief (you can find a list at Migraine Research Foundation). But there aren’t that many specialists, so you may get help if you see a neurologist or get referred to one from your primary care provider.
What Can I Take to Stop a Migraine Attack?
There are more options than ever, and they include drugs ranging from ordinary pain relievers to newer, more targeted injectable drugs. If you can’t take these medications, then there are non-drug devices you can try. Usually, doctors will recommend taking only acute treatments to people with episodic migraines, especially if they only have one or two attacks per month.
You take acute medications at the first signs of a headache, not during the aura (if you are one of the 20% people with migraines who have them). Ideally, any treatment you use to stop a migraine should work in two hours or less—and your pain shouldn’t come back later (even a day later). If that’s not the case, it’s time to switch medications (or move on to preventative ones).
These are the drugs most migraine patients end up taking, but they work best if you don’t have many attacks and the pain isn’t that bad. They’re usually sold over-the-counter (OTC), though sometimes a doctor can write an Rx for stronger doses. Take them soon after the headache begins, but don’t take more than the recommended dose in a day, and skip them if you have two or more headaches a week.
The reason: People can get rebound headaches when these OTC drugs are overused, which then can be difficult to treat. Plus, taking too many NSAIDs like Advil (ibuprofen) could put you at risk for such gastric issues as bleeding or ulcers, which people with migraines are three times more likely to get. So if you’re popping over-the-counters like candy, ask your doctor about prescription options (including preventative meds).
OTC pain relievers include:
NSAIDs like Aleve (naproxen sodium) and Advil (ibuprofen), which tend to work best because they lower the inflammation caused by an attack
Excedrin (aspirin, acetaminophen, and caffeine)—which can help because the caffeine can constrict the blood vessels
If your migraines are getting more frequent and intense and your OTC drugs aren’t helping, your doctor might recommend a triptan, which activates serotonin receptors in your brain. Experts think abnormal levels of serotonin, a brain chemical that helps your brain cells communicate with one another, may make you more sensitive to pain (as well as depression). Serotonin may also help activate another chemical called CGRP, which is released during a migraine attack.
Triptans come in tablets, nasal sprays, and dissolving tablets, and you take them as soon as you feel a migraine coming on. They usually work in about 30 to 60 minutes, and they’ve been found effective in about half to 80% of all migraine patients. They can make your queasy feelings worse (or bring them on) and they’re not recommended for people with high blood pressure, those who suffer from hemiplegic migraines, during pregnancy, or for those with Raynaud syndrome. You can also rely on them too much if you’re a chronic migraine sufferer and make things worse.
These drugs include:
Maxalt, Maxalt-MLT (rizatriptan), also comes in a dissolving tablet and is okay for kids 6 years and older to take, too
Imitrex (sumatriptan), also comes in a spray
Zomig, Zomig ZMT (zolmitriptan), also comes in a dissolving tablet
If triptans don’t work for you, your provider might put you on these drugs, which work by constricting the blood vessels in the brain. Again, you take them at the first signs of an attack. Ergot alkaloids do have side effects (like nausea and vomiting), and you can’t take them if you’re pregnant or breastfeeding, have heart disease, chest pains, or have a risk of strokes, since they can raise that risk.
These drugs include:
Migranal (dihydroergotamine), a nasal spray
Ergomar (ergotamine), a tablet you place under your tongue
Drugs That Block CGRP Receptors
CGRP is a peptide (a small protein molecule) that attaches to nerve endings in the brain responsible for transmitting sensory information, and when you have an attack, its levels increase.
These meds target the CGRP receptors, blocking the protein from attaching to the nerve endings. They come in tablets and typically provide relief within two hours from both pain and symptoms like nausea and light sensitivity for roughly 60% of people.
One in five migraine patients, according to clinical studies, were completely free from pain. The drawbacks? These drugs are expensive, and in order to get insurance to cover them, you have to have tried (and failed) older drugs (like triptans). The side effects include nausea and fatigue but just about anyone who has episodic or chronic migraines, including those with cardiovascular issues, can take these drugs.
Non-Drug Options for Acute Migraines
Neuromodulation devices are machines that you use at home when you can’t (or don’t want to) take medications, and they all work by stimulating neural pathways in the brain to relieve pain. Women who are pregnant or trying to conceive as well as older folks who can’t tolerate drugs or those who can’t tolerate side effects are all good candidates for these at-home devices. These at-home machines have no side effects and sometimes can be used to prevent attacks as well as stop them, no matter what type of migraine you have. The drawbacks? They’re not covered by health insurance unless you’re a veteran and get your health coverage through the Veterans Administration.
Cefaly (transcutaneous electrical nerve stimulation)—It looks a bit like a heart monitor that attaches to your forehead via a sticky electrode. It’s used for both prevention and during an attack and works by buzzing the forehead and stimulating the nerves that go into the brain. When you feel a migraine coming on, you put it on and leave it for an hour. One small study found that it cut pain by more than half (57%) after one hour, and none of the patients needed to take other meds. This device costs $499 to buy, and about $25 every three months to replace the electrodes.
sTMS-mini (single-pulse transcranial magnetic stimulation)—This device is about the size of a shoe and contains a magnet. You place the sTMS-mini at the back of your head, turn it on, and the magnet pulses four times, stimulating the electrical activity in the brain. It’s used both for prevention and during an attack. A study published in the Lancet found that more than one-third of patients were pain free after two hours. Only a doctor can prescribe the sTMS-mini, and the costs are hefty—$250 a month to rent (you may get a break through the manufacturer).
GammaCore (non-invasive vagal nerve stimulator)—It looks like an electric razor and you place it on your neck for two minutes at a time, about two or three times in a row (so for about four to six minutes total), when you have a migraine. GammaCore stimulates the vagus nerve, which runs from the brain through your face and neck down to your abdomen, blocking pain signals. More than a third of patients are pain-free in an hour and many cut down the number of attacks per month. It too is costly—$600 a month to recharge it (and you need an Rx to do it).
Nerivio—This high-tech option is only good for those with episodic migraines. It includes a patch that you wear on your upper arm that’s controlled via a smartphone app. You turn on the device within 60 minutes of an attack and it sends signals to the brain stem to block you from feeling pain. The sooner you turn on the device, the greater the pain relief, a study published in Neurology found: For those who’d used Nerivio within 20 minutes of symptoms, 58% reduced the pain of the attack by half, and about 30% were pain free in two hours. The patch costs $99, and it can treat 12 attacks.
What Can I Take to Prevent Migraines From Starting in the First Place?
All of the following medications are taken to lower the number of attacks you have a month and, with any luck, make them less severe. Doctors prescribe them to anybody who has migraines—episodic or chronic, with auras or without. Usually, you want to use them if you have more than four attacks per month or they’re super debilitating.
Just be aware that even with preventative meds or devices, you’ll need to take something else during an attack. So, for instance, if you decide on Botox shots, you’ll probably have fewer episodes a month, but you’ll probably need a triptan or some other pain reliever when you do get a migraine.
Off-label drugs. Sometimes doctors will prescribe drugs that are meant for other things to prevent headaches. You take these pills every day to stop the frequency of attacks. The problem is that these drugs come with some serious side effects, like fatigue, depression, or loss of libido, so people tend to stop using them after a while.
Birth control pills will prevent a quick drop in estrogen and are given to women who have attacks right before or during the periods. These aren’t the best choice for women who have migraines with auras, because their risk of stroke goes up four or five times—and if they’re on birth control it goes about seven times. And if you smoke, the risk goes up nine times, which is why most doctors won’t recommend them if you have auras.
Anti-depressants that raise serotonin levels, like Elavil (amitriptyline) and Effexor (venlafaxine)
Blood pressure medications that can constrict blood vessels, like Inderal (propranolol) and Lopressor (metoprolol)
Anti-seizure medications that can work on glutamate receptors and block excessive, another neurotransmitter involved in migraine auras, like Topamax (topiramate)
Botox shots. The same injections that can make your forehead smoother and erase lines can also prevent migraines—although they are only approved for people with chronic migraines. A doctor injects Botox at several points around your head and neck (as many as a dozen or even more). The toxin blocks the release of chemicals that cause pain. Each set of injections last about 12 weeks.
CGRP-binding drugs. These preventative injections are designed to lower the number of attacks you have a month—cutting them at least by half for 50% of patients in clinical studies done on these drugs. They are designed to bind to CGRP molecules and block them from attaching to the receptor. You take these medications once a month, and you can get the shot at the doctor’s office or give it to yourself (after your provider shows you how). The side effects include pain and redness at the injection site (typically your thigh or stomach), nausea, and constipation.
The headaches are also less severe, so patients in studies reported a better quality of life—missing fewer days at work, not having to skip family or social events, having less trouble concentrating and feeling exhausted.
These meds include:
Two of the same at-home brain stimulating devices that can treat your migraines can also reduce the number of migraine days if you use them for prevention as well.
Cefaly—Turn it on every evening for 20 minutes. One small study found that the number of attacks dropped from an average of seven a month to slightly fewer than five.
sTMS-mini—Give yourself four pulses in the morning and four pulses at night for prevention. One study found that about 46% of patients cut the number of migraines by at least half.
Complementary or Lifestyle Treatments
Along with medical treatments, you can also try tweaking your diet and other parts of your life that may be triggering attacks, like insomnia or stress.
Getting better sleep. Insomnia as well as other sleep disorders like sleep apnea have been linked with migraines, both as triggers and as another accompanying chronic condition. If you wake up with headaches, the quality and quantity of sleep may be to blame. A doctor may work with you to get you on a sleep schedule (going to bed and waking up at the same time) as well as other aspects of sleep hygiene (like, say, keeping your bedroom cool or keeping your phone on the other side of the room). Or connect with a therapist who can teach you specialized cognitive behavior therapy strategies designed to help you fall asleep and stay that way more easily.
Eat healthier foods. There is some evidence to show that obesity can turn episodic migraines into chronic ones. There’s no one anti-migraine diet, but try to eat more plant-based meals and swap out unhealthy foods like soda and sugary treats for more fruits and veggies. And keep to a regular eating schedule to keep blood sugar fairly even. One trigger for many people is skipped meals or going too long before eating.
See an acupuncturist. You can lop off an average of three-and-a-half days of migraine attacks with 20 sessions of acupuncture, according to Chinese researchers. The caveat: This small study was done on people with episodic migraines without auras. Either way, the therapy can be very relaxing, and there’s nothing wrong with having an excuse to lie quietly in a comfy, dark room.
Try magnesium supplements. If you want to prevent migraines from happening and aren’t keen on spending money on devices or other drugs, try taking 400 to 500 mg of magnesium oxide every day. It works best on those who have migraines with aura as well as people who have auras but have no or very mild headaches after their aura signs. Magnesium can block a receptor in the visual processing part of the brain that’s activated by glutamate, the area in the brain most implicated in auras.
Other supplements that may help (or at least are worth a discussion with a provider):
vitamin B2 (riboflavin)
In studies, each of these supplements were found to cut down the frequency of migraines perhaps because of their anti-inflammatory, antioxidant properties. Melatonin can also help you sleep better, which can also help cut down the number of attacks, and it may also block CGRP release, which helps lessen the pain. Some of these supplements even come in combo form, like Dolovent (magnesium, coenzyme Q10 , and B2).
Manage your stress. Like sleep, people with migraines are stressed and have anxiety, and that may lead to other unhealthy coping strategies like smoking, taking too many medications, and over-eating. So it makes sense that anything that can get you to relax will be good for your overall health as well as your migraines. There have been a few evidence-based techniques that can work to reduce migraine pain as well as frequency, including cognitive behavior therapy (CBT), whether online or group sessions, as well as mindfulness techniques, which also work well for those people whose migraines have gotten worse because they over-use medications. There’s also some evidence to show that doing yoga can also cut down the number of attacks and the intensity of migraine pain.
Migraine Treatment Statistics: National Headache Foundation. (n.d.). “Statistics from the American Migraine Prevalence and Prevention Study,” headaches.org/2011/04/08/statistics-from-the-american-migraine-prevalence-and-prevention-study/
Migraine Treatment Overview: Pain Treatment and Research. (2015). “Evidence-Based Treatment for Adults With Migraines.” ncbi.nlm.nih.gov/pmc/articles/PMC4709728/
Problems With Migraine Care: Headache. (2016). “Assessing Barriers to Chronic Migraine Consultation, Diagnosis, and Treatment: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study.” ncbi.nlm.nih.gov/pubmed/27143127
CGRP Targeted Treatments: Institute for Clinical and Economic Review. (2020). “Acute Treatments for Migraine: Evidence Report.” icer-review.org/wp-content/uploads/2019/06/ICER_Acute-Migraine_Evidence_Report_011020_updated_011320
Cephaly Device and Pain Relief: Neuromodulation. (2017). “External Trigeminal Nerve Stimulation for the Acute Treatment of Migraine: Open-Label Trial on Safety and Efficacy.” ncbi.nlm.nih.gov/pubmed/28580703
sTMS-mini Acute Pain Relief: The Lancet (2010). “Single-pulse transcranial magnetic stimulation for acute treatment of migraine with aura: a randomised, double-blind, parallel-group, sham-controlled trial.” thelancet.com/journals/laneur/article/PIIS1474-4422(10)70054-5/fulltext
sTMS-mini Prevention: Cephalagia. (2018). “A multicenter, prospective, single arm, open label, observational study of sTMS for migraine prevention (ESPOUSE Study).” ncbi.nlm.nih.gov/pmc/articles/PMC5944078/
Nerivio and Pain Relief: Neurology. (2017). “Nonpainful remote electrical stimulation alleviates episodic migraine pain.” n.neurology.org/content/88/13/1250.short
Lifestyle Interventions: Cleveland Clinic Journal of Medicine. (2019). “SEEDS for Success: Lifestyle Management in Migraine.” ccjm.org/content/86/11/741
Magnesium Supplements: American Migraine Foundation. (2013). “Magnesium.” americanmigrainefoundation.org/resource-library/magnesium/
Integrative Medicine and Migraines: Current Headache and Pain Reports. (2019). “Complementary and Integrative Medicine for Episodic Migraine: an Update of Evidence from the Last 3 Years.” ncbi.nlm.nih.gov/pubmed/30790138
Yoga and Migraines: Journal of Physical Therapy Sciences. (2015). “Effects of yoga for headaches: a systematic review of randomized controlled trials.” ncbi.nlm.nih.gov/pmc/articles/PMC4540885/
Acupuncture and Migraines: BMJ. (2020). “Manual acupuncture versus sham acupuncture and usual care for prophylaxis of episodic migraine without aura: multicentre, randomised clinical trial.” ncbi.nlm.nih.gov/pubmed/32213509