Clinical Overview: Assessing Different Treatments for Migraine Headaches

There are many different types of headaches, the most common of which are tension, sinus, exertion, hypertension, hormones, cluster, and migraine headaches.^1,2

Knowing the identifying factors and triggers for migraines is important because there is an overlap of information and different treatment modalities amongst the different types. Migraines can be triggered by getting too little sleep, bright or flickering lights, and stress.³

Other common triggers include food, alcohol, caffeine, menses, red wine, smoking, changes in the weather, and use of artificial sweeteners, such as aspartame.³ Each trigger can affect and worsen each other, exacerbating the migraine further.

Migraines are among the biggest causes of disability, preventing patients from participating in work, family, and social events, which decreases their quality of life.^1,2 There are major negative physical and financial impacts migraines can have on individuals.³

Approximately 38% of patients with migraines that come in episodes can find relief from prophylactic treatment.³ There is a growing body of evidence that foods, substances, and additives in vitamins and supplements can be a trigger for migraine headaches.

Agents such as phenylethlamine, tyramine, aspartame, monosodium glutamate (MSG), nitrites, and ethanol can affect people who are hypersensitive to these agents.⁵ Keeping a diary, notating the time, and writing down notes of what occurred can help health care providers identify the triggering cause.⁵

Non-pharmacologic migraine treatment

Modifying lifestyle factors—such as maintaining a healthy sleep pattern, consuming plant-based healthy meals, and physical exercise to reduce stress—are key in treating and preventing migraines naturally.⁴ Because migraines are often caused by dehydration, adequately staying hydrated and preventing dehydration can have a major impact on the onset of developing a migraine.

In addition, having set work routines and schedules are crucial in maintaining a healthy work-life balance to keep migraines at bay.⁴ Magnesium, feverfew, coenzyme Q10, riboflavin, and alpha lipoid acid are OTC options that patients may use to self-treat their migraine headaches.⁵ If patients cannot find relief non-pharmacologically and the number of migraine headaches increase, the next step would be to follow-up with their physician.²

Pharmacologic migraine treatment

To be considered for prophylactic treatment, the patient should have suffered from 4 or more headaches per month or if the headache occurred at least 8 days per month.³ Preventative treatment or prophylaxis therapy can be selected from a new class of drugs called calcitonin gene-related peptide (CGRP) antagonists, which have been FDA-approved in adults for prophylactic treatment.

Prophylactic therapy can improve quality of life and slow the worsening of the current state of the migraine into a chronic migraine.³ CGRP medications include eptinezumab, fremanzumab, and erenumab.¹

Medications with the highest level of evidence or first-line agents for episodic migraine prevention include divalproex (Depakote), metoprolol, propranolol, frovatriptan (Frova), topiramate (Topamax), and timolol. Second-line agents include amitriptyline (Elavil), venlafaxine, zomatriptan (Zomig), atenolol, nadolol (Corgard), and naratriptan (Amerge).³

Acute treatment is approached by using medications called triptans and ergotamines, and/or analgesics.^2,4 Commonly used triptans include sumatriptan, zolmitriptan nasal spray (Zomig), rizatriptan ODT (Maxalt MLT), and zolmitriptan ODT (Zomig ZMT). Common ergotamines include dihydroergotamine and ergotamine.⁴

There’s positive evidence that the use of acetaminophen (Tylenol) and non-steroidal anti-inflammatory drugs, such as ibuprofen, aspirin, and diclofenac can mitigate migraine attacks.⁴

Conclusion

Additional treatments are still being developed to further open the window of hope for those who cannot get adequate or sustainable relief from current treatments because of financial or contraindicative factors.

References

1. Peters GL. Migraine overview and summary of current and emerging treatment options. Am J Manag Care. 2019 Jan;25(2 Suppl):S23-S34.

2. Silberstein SD. Migraine. Lancet. 2004 Jan 31;363(9406):381-91. doi: 10.1016/ S0140-6736(04)15440-8.

3. Ha H, Gonzalez A. Migraine Headache Prophylaxis. Am Fam Physician. 2019 Jan 1;99(1):17-24.

4. Aguilar-Shea AL, Membrilla Md JA, Diaz-de-Teran J. Migraine review for general practice. Aten Primaria. 2022 Feb;54(2):102208. doi: 10.1016/j.aprim.2021.102208. Epub 2021 Nov 16. PMID: 34798397; PMCID: PMC8605054.

5. Sun-Edelstein C, Mauskop A. Foods and supplements in the management of migraine headaches. Clin J Pain. 2009 Jun;25(5):446-52. doi: 10.1097/AJP.0b013e31819a6f65.