ACUTE VS PREVENTATIVE MEDICATIONS FOR MIGRAINE
Migraine is a debilitating condition that affects many people worldwide (over 15% of the population!). It is a condition that is invisible, stigmatized, and poorly understood. We know that migraine is both underdiagnosed and undertreated. Combining all the days an individual is affected by migraine over their lifetime results in years of disability. Migraine is not “just a headache.” It is a neurological illness with a profound effect. However, migraine can be well managed by healthcare providers with expertise in this area.
Developing an effective migraine management plan is crucial to limiting attacks and disability. This plan consists of a few essential components. Sometimes I describe these as being like the legs of a table. If you’re missing one of the legs, then the table is unstable and will likely collapse. The same thing happens when you’re missing one of the essential components of your migraine management plan.
What are the components of an effective treatment plan?
Lifestyle and behaviour strategies
Support network (friends, family, mental health supports, healthcare providers)
Acute treatment plan (what to do when you get a migraine)
Preventative treatment plan (what to do to prevent or reduce migraines from starting)
I’m going to review the components and goals of the acute and preventative treatment strategies for migraine. Often the differences between these approaches are not very well understood and just need to be optimized to make a HUGE improvement in migraine attacks.
See my blog post on “Migraine Management without Medication” to review the lifestyle and behaviour based strategies that are part of a migraine management plan.
These are “as needed” medications to be taken for a migraine attack and can be either over-the-counter or prescription medications. The goal of acute treatment is to stop an attack once it has started by reducing the pain and other associated symptoms of migraine and allowing a person to return to function. Acute treatment is the rescue plan that will extinguish the fire. However, these treatments will not prevent migraines from happening or reduce the frequency of attacks. This is an important difference because many migraine sufferers may wonder why their migraine attacks are increasing over time or not responding as well to their acute treatment. It is often because they don’t have any prevention in place.
What should you expect from your acute medication? Pain relief or pain freedom within 2 hours, minimal side effects, and the ability to return to function within 2 hours. If an acute medication only “takes the edge off” and does not improve your function, then your acute treatment may need to be optimized or changed.
A simple approach to optimizing treatment is assessing when the medication is being used. Delaying treatment beyond an hour significantly decreases the chances that it will work. So treat the attack EARLY! Back to my fire analogy - if you have a fire on your stove and you reach for that extinguisher right away - no problem. But if you leave it for hours, then that extinguisher will be of no help. Think of your acute treatment this way as well.
There is an important caveat to this advice. Acute medications should be taken as early as possible in the attack BUT using them too often can result in a Medication Overuse Headache (yes, that is a diagnosis). How often is too often? Typically acute medication should be used less than 10 days of the month to avoid a medication overuse headache. These types of headaches often present as a rebound the following day or once the acute medication has worn off. As many as HALF of chronic migraine sufferers also have medication overuse headache (stay tuned for a future blog post on this topic).
If you are reaching for acute medication more than twice a week, it is time to speak to a healthcare professional about preventative treatment options! Starting a daily preventative medication may seem like a big choice, however, it can decrease your symptoms substantially, help you to avoid a medication overuse headache, and could decrease the migraine symptoms by 50%.
WHAT ARE EXAMPLES OF ACUTE TREATMENT?
Acute treatment can be classified into various categories including analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), and triptans. Acetaminophen (Tylenol) is an analgesic. NSAIDS include over-the-counter options such as ibuprofen (Advil, Motrin) and naproxen (Aleve). There are also a range of prescriptive NSAIDS. Triptans are a class of prescriptive medications that are specifically designed to treat migraine headaches. We have 7 triptans available in Canada. When migraines don’t respond to NSAIDs or acetaminophen, we may consider trying a triptan. If one triptan doesn’t work for you, it may be worth trying others until you find one that works. Your healthcare provider can help you with this.
A note on opioids - there is no evidence to support using opioids in managing migraine. In fact, the risks and negative outcomes are well documented. They often lead to medication overuse headache and can result in dependence. Avoid these as part of your migraine treatment or see a headaches specialist if you need help with alternative treatment options.
Preventative treatment is used to reduce the frequency and intensity of migraine attacks. Preventive treatment may be needed if you have 3 or more migraine attacks per month. There are both prescriptive medications as well as natural supplements that can help to control migraines.
Preventative treatments are used on a regular basis (daily for oral medications or at specific intervals for injectable treatments). It is important to understand the expected goal of prevention. We aren’t curing migraines or turning off the attacks - the hope is to gradually reduce the severity, frequency, and/or duration of migraine attacks. This won’t happen immediately. It often takes 8 or more weeks to see some improvement and then it is a slowly gained improvement.
To assess the need or effectiveness of a preventative treatment, It is essential to keep track of migraine attacks and acute medication use through a headache diary. This provides essential information to guide medication choices and will provide you with valuable insight into patterns, triggers, and other symptoms. Your headache diary will help your healthcare provider put together a treatment plan that is tailored specifically to you and your lifestyle/needs, and will increase the chances of a positive outcome. Check out my last post to learn more about keeping a headache diary!
WHAT ARE EXAMPLES OF PREVENTATIVE TREATMENT?
You may be happy to know that there are natural supplements that are beneficial in migraine prevention. These supplements include magnesium, B2 (riboflavin), and coenzyme Q10. Always check with your healthcare provider before starting any treatments to find out if there are any side effects or interactions you should be aware of. Migraine Canada has a great post on these supplements here: Supplements for Migraine.
Some tips for supplements: They may take 8-12 weeks of regular use to see effect, they need to be taken daily, they are not usually enough for chronic migraine sufferers. The biggest downside to supplements is that they can be costly.
If supplements are not effective on their own, there are several prescriptive options for preventative treatment. How effective are these medications? Approximately 50% of people will have a 50% improvement in their migraine attacks. Unfortunately, we don’t have a way to determine who will respond best to a particular medication. Migraine treatment is a journey and a partnership between you and your healthcare professional. We may have to go back to the “drawing board” several times to find the right treatment plan that will reduce the impact of migraine attacks and improve quality of life and function.
Oral preventative medications come from classes that are not specific to migraine. For example, we may use a blood pressure (anti-hypertensive) medication. We’re not using it to treat blood pressure and the dosing may be different but we know that these medications can also decrease or improve migraines. We also use medications from anti-depressant and anti-seizure classes. It is important to have a healthcare provider who can help you navigate and understand these treatment options. Are there side effects? There can be side effects but this is different for every person. A conservative approach with gradual increases with lower doses can sometimes help. This is where the partnership with your healthcare provider comes in!
For many years these non-migraine oral medications were the only options that we had for prevention. However, there are injectable treatments such as Botox which has been approved for chronic migraine in Canada since 2011. It can be very effective in treating chronic migraine if administered by a provider who is experienced in using it for this purpose. Botox has many years of safety data and tends to have very minimal side effects. More recently, an entirely new class of medications - the CGRP monoclonal antibodies - became available as the first migraine-specific preventative treatment. These injectable medications work to prevent release or binding of some of the neurochemicals that are involved in sending pain messages in a migraine attack. This is an exciting new advancement in migraine care and we will see a number of new medications coming to Canada in the coming years.
Migraine Canada has an excellent chart summarizing the preventative treatments used in migraine here: Preventative Treatments.
Finding a healthcare provider who is knowledgeable in all strategies to manage migraines - include non-medication lifestyle and behavioural strategies is essential.
We don’t have a cure for migraines so we are aiming to control attacks, reduce disability, and improve quality of life. This can take time, patience, and a strong therapeutic relationship. Every person with Migraine is a unique individual and their treatment plan will be developed collaboratively taking into account their values, needs, and goals. Just remember - there is always something more than can be done to help control your migraine attacks.