16 Chronic Migraine Treatments Recommended by Headache Specialists
When the pounding in your head starts to interrupt your life, it's time to talk to a doctor about what your options are. Treatment for chronic migraines can be split into two categories: preventative treatments and acute (also called "abortive") treatments, which help to stop a migraine in its track when they do occur.
"Most people with chronic migraines are taking both a preventive medication and have an acute medication to use as needed," according to Mason Dyess, DO, a general neurology and headache medicine physician at Ochsner Medical Center in New Orleans.
Medications to prevent chronic migraine
Preventive medicines are "medicines that you would take scheduled on a daily basis or injections on a monthly basis," Dr. Dyess explains. "Whatever your regimen is, it's helping you actually prevent headaches from occurring."
Preventive medicines include:
Blood pressure medications
Blood pressure medications, like beta-blockers, can be "very effective" at preventing migraines, Dr. Dyess says. "We typically start out at doses lower than a typical patient would use for actual blood pressure," he explains. As far as why they work, he says there's a concept called cortical spreading depression (CSD)—a wave of activity across the surface of the brain—and doctors think these medicines can interrupt the spreading process of a migraine.
Amitriptyline has long been used to prevent migraines, but side effects like weight gain, dry mouth, and extreme sleepiness mean it's not a good fit for everyone. Another option is venlafaxine (Effexor), different type of antidepressant. Each is considered "probably effective" in migraine prevention, according to the American Headache Society's latest consensus statement on migraine treatments.
Anticonvulsants, such as topiramate or gabapentin, may be tried as a preventative migraine therapy. "We think that part of the issue with migraine is that your nerves become hyperexcitable, meaning that they fire more easily and become more irritated easily," Dr. Dyess says. "We think that these anticonvulsants help calm the nerves and prevent them from being activated and causing more pain." But side effects include dizziness, weight changes, and nausea, and they're not recommended for people who are pregnant or are trying to become pregnant.
Botox injections are approved specifically for chronic migraine sufferers. On a basic level, botox "decreases sensory input around the face and neck," says Robert Cowan, MD, professor of neurology and chief of the division of headache medicine at Stanford University. But there may be more to it than that. "We also think that chemically Botox helps dial down inflammation," Dr. Dyess adds.
Calcitonin gene-related peptide (CGRP) inhibitors
Studies show that blood levels of CGRP, a chemical messenger, are elevated during a migraine attack, according to a review in the Journal of Headache and Pain. That observation has led to two classes of CGRP blockers.
Monoclonal antibodies. Drugs like Aimovig (erenumab-aooe), Ajovy (fremanezumab-vfrm), and Emgality (galcanezumab-gnlm) block the effects of CGRP, says the US Food and Drug Administration (FDA). Injected on a monthly or quarterly basis, the effects of these medicines can last for months, and they're well-tolerated by most people—the most common side effect is pain at the injection site, per the American Migraine Foundation. Another monoclonal antibody, Vyepti (eptinezumab-jjmr), was approved in 2020 as the first intravenous treatment for migraine prevention, notes the American Headache Society.
CGRP receptor antagonists. These oral medicines work by stopping the inflammation that leads up to a migraine, Dr. Dyess explains. Nurtec ODT (rimegepant) is the only one approved both as a preventive and acute medicine, the American Headache Society points out. Per the manufacturer, common side effects include nausea, stomach pain, and indigestion.
Medications to treat chronic migraine
There are a few options for knocking out a migraine when you're in pain. "The acute medications are supposed to be employed at the very first sign of migraine. So you start having pain, you take the medicine," Dr. Dyess explains. "It, in theory, will help to eliminate the headache in a timely fashion so that you can go about your day."
Acute medications include:
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Many NSAIDs, like aspirin, ibuprofen, and acetaminophen are available over the counter, which makes them a convenient option. But they're usually only effective against mild migraine pain, according to the Mayo Clinic, and if they're taken for too long can actually cause headaches, as well as digestive issues like ulcers and gastrointestinal bleeding.
Triptans are one of the main headache-specific drugs recommended by doctors for chronic migraine. Common brands include Imitrex (sumatriptan) and Maxalt (rizatriptan). Triptans work by stimulating serotonin, reducing inflammation, and constricting blood vessels, according to the National Headache Foundation. They're most effective when taken early in the migraine.
Dihydroergotamine, sold under the brand name Migranal, is available as a nasal spray or an injection, and it's most effective when taken at the very start of a migraine that would otherwise last longer than 24 hours, according to the Mayo Clinic. It can worsen nausea and vomiting in some people, and isn't a good fit for people with coronary artery, kidney, or liver disease, or for people with high blood pressure, Mayo notes.
CGRP receptor antagonists
As previously mentioned, Nurtec ODT is approved to prevent migraines as well as treat migraine pain. Another medicine in this class, Ubrelvy (ubrogepant), is approved for the acute treatment of migraine. In drug trials, CGRP receptor antagonists have been shown to reduce pain, nausea, and light sensitivity within two hours, according to the Mayo Clinic. Ubrelvy's side effects include nausea, dry mouth, and excessive sleepiness, according to the manufacturer, Allergan.
Approved in 2019, Reyvow (lasmiditan) is the first drug in its class. In clinical trials, substantially more people experienced migraine symptom relief within two hours versus those who took a placebo, according to manufacturer Eli Lilly and Company. For people who haven't found success with triptans, ditans may be an option. These drugs are believed to work by targeting a certain type of serotonin receptor on nerves that transmit headache pain, per Harvard Health Publishing. Common side effects include dizziness and sleepiness.
"Nausea is a very common migraine complaint," says Dr. Dyess. "So having a nausea medicine is very helpful." But these medicines might help beyond reducing nausea, says Dr. Dyess. The way these drugs work may also help "shut down the migraine," he says. Options include metoclopramide and prochlorperazine, per a 2018 review in American Family Physician.
Complementary and alternative treatments for chronic migraine
If you've had chronic migraines for long enough, you've likely been recommended a host of different supplements. Unfortunately, most are ineffective at best. "If you were to Google supplements for migraine, the vast majority of those supplements do not have significant amounts of research behind them," Dr. Dyess says.
But complementary treatments are a viable option for some people. "The challenge is that these require active engagement on the part of the patient, and results are not typically immediate as they can be with some of the pharmaceuticals," says Dr. Cowan. "A lot of this hinges on patient preference."
A few complementary treatments for chronic migraine that have shown promise include:
"It's been proven safe in a variety of settings for headache," Dr. Dyess says. It seems to help people who have migraine with aura in particular, and women with menstrually-driven migraines, according to the American Migraine Foundation. It's also safe for use in pregnant women, which is not true for some migraine medications.
There's some evidence that high doses of riboflavin (B-2) reduce the number of migraines by about two migraines a month, according to the US National Library of Medicine.
Coenzyme Q10 (CoQ10)
A review and analysis of six small studies found no significant reduction in migraine severity with CoQ10 supplementation. But the compound may have other benefits. The 2020 study in BMJ Open found the duration and frequency of migraines with CoQ10 was significantly reduced compared with a control group.
Remote electrical neurostimulation (REN)
Nerivio, a wearable REN device, delivers electrical pulses to nerves in the upper arm. It's believed that the brain responds to those signals by activating the body's own ability to squelch pain in another part of the body. This non-pharmaceutical treatment may be a viable alternative for people with chronic migraine, per a study of the device's safety and efficacy published in Pain Reports. Tingling in the arm is a common side effect. The American Headache Society says REN may reduce medication-overuse headaches.
Mindfulness, biofeedback, and other awareness techniques
"Migraines are very stressful when they're happening. They're very stressful on your family and your family dynamics that take a huge toll in your life," Dr. Dyess says. Cognitive behavioral therapy, mindfulness, and even biofeedback (which teaches patients to monitor and control their heart rate) can help people manage stress and deal with the effects of migraine. "A lot of people use it as a way of dealing with the pain in real time," he adds.
Bottom line: stay in conversation with your doctor when it comes to complementary techniques. "I'm always open to trying whatever works to control their pain and control their migraines as long as it's safe," Dr. Dyess says.
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