Treating Migraines & Headaches
Migraines and headaches are used interchangeably but what distinguishes one from the other? Both result in head pain and discomfort, but migraines are typically more severe and accompanied with other symptoms. SIMEDHealth Neurologist, Dr. Anthony Ackerman, explores the causes, symptoms, and options for treating migraines and headaches, shedding light on the key differences between them. If you're experiencing reoccurring migraines, a SIMEDHealth Neurologist can help develop a personalized treatment plan for you. To request an appointment with our Neurology department, click here.
I. What are the general types of headaches?
Headaches are a common complaint seen in a primary care, urgent care and neurology clinics. They can be debilitating, leading to decreased quality of life, work place productivity and quality time spent with family and friends. The more common headaches are migraine, tension and cluster; however, there are many other headache types as well.
II. What are common symptoms of migraine headaches?
The most common migraines are: 1) one-sided headaches; 2) headaches that are throbbing or pulsating in character; 3) headaches associated with light/noise/odor sensitivity, and/or nausea/vomiting. Some migraines are preceded with an aura, often visual disturbances (e.g., flashing lights, zig-zag lines, spots or missing spots in visual field). However, there are many other migraine types. Complex migraines can have stroke-like symptoms (e.g., loss of vision, changes in sensation, weakness, word-finding difficulties, slurred speech, unequal pupil size, etc.) followed by a headache. Sometimes you can have the stroke-like symptoms without headache, and with no evidence of a stroke on diagnostic evaluation. These are referred to as atypical migraines. There are ocular migraines (with visual disturbance) or vertiginous migraines (with associated vertigo or spinning sensation), both without headaches. Hemiplegic migraines consist of a temporary one-sided weakness but often with associated visual disturbance or sensory symptoms (numbness or tingling). This type of migraine can often run in families. Basilar migraines can have associated slurred speech, vertigo, ringing in the ears, double vision, decreased hearing, coordination problems or decreased levels of consciousness.
III. What are the causes of migraine headaches?
Migraines can have a genetic component, meaning they can be inherited. These involve the dysfunction of ion channels regulate neurotransmitters or neuropeptides, including serotonin (5-HT), calcitonin gene-related peptide (cRGP), and substance P. Alterations in these levels affect pain perception, blood flow or inflammation in the brain. Decreased blood flow in regions of the brain can contribute to a migraine's aura, symptoms preceding a headache. These changes can involve the trigeminal nerve (the nerve most commonly associated with sensation to the face), the meninges (the lining of the brain) as well as various regions of the brain itself. Typically, imaging the brain, with CT or MRI will not show any obvious cause of migraines.
IV. What treatments are available for migraines?
Fortunately, there are many medications available used in treating migraines. There are two basic approaches to managing headaches: abortive and prophylactic medications.
Headache abortive therapy
An abortive therapy is used to treat the headache during the aura prior to the headache starting, or as soon as possible after it starts. The goal is to prevent, or relieve the headache within minutes to hours. The most common over-the-counter abortive therapies include: acetaminophen, NSAIDs (e.g., aspirin, ibuprofen, naproxen, aspirin/acetaminophen/caffeine preparations).
Commonly used prescription abortive medications include:
1) NSAIDs (e.g., diclofenac, higher dose ibuprofen), which are commonly paired with an anti-nausea medication such as Compro (prochlorperazine), Phenergan (promethazine) or Zofran (ondansetron). Sometimes Benadryl (diphenhydramine) is taken with the headache abortive and anti-nausea medication for a type of "migraine cocktail."
2) Triptans (e.g., Imitrex (sumatriptan), Maxalt (rizatriptan), Relpax (eletriptan), Zomig (zolmitriptan), Midrin (isometheptene) and DHE (dihydroergotamine). Generally triptans and ergotamine should be used with caution in older individuals, especially in patients with cardiovascular or cerebrovascular disease.
3) An in-office intramuscular Toradol (ketorolac) injection and short burst of the steroid prednisone can be effective short term abortives for intractable headaches, and may reduce patients’ need to seek care at an immediate care center or emergency room. Some physicians regularly prescribe barbiturates (e.g., butalbital-containing products) and/or opiates (e.g., hydrocodone, oxycodone, butorphanol, tramadol) for headache abortives, which may temporarily relieve headaches; however, the potential risks of abuse, dependency and rebound symptoms far outweighs their potential short-term benefit. The American Association of Neurology highly advises to avoid barbiturates and opiates, especially for first-line therapy, and only use them as a last resort, especially since there are many effective alternative migraine headache abortive therapies available (February 21, 2013). Any headache abortive, whether it be over-the-counter or prescription medication, used more than 2-3 days per week, puts the patient at high risk of developing medication overuse/rebound headaches, leading to intractable headaches continuing to recur as long as the offending medication is taken. The fastest means of breaking the rebound headache cycle is to stop the medication “cold turkey,” at which time the headache will initially worsen before it improves, typically over a period of a week. Someone who is unable to stop abruptly may consider tapering off the medication, although this may delay the recovery. A short burst and then taper of prednisone can frequently reduce the discomfort during the withdrawal of the overused analgesic. Patients who are unable to stop taking daily analgesics or who have intractable headaches may benefit from intravenous headache abortive therapy, including DHE, Thorazine (chlorpromazine), valproic acid and the steroid dexamethasone.
Headache prophylaxis (preventative) therapy
Individuals with more than two or three headaches per month, or with post-concussion headaches may benefit from an anti-headache medication taken on a daily basis. This type of medication does not relieve or improve headaches immediately but rather over 3 to 4 weeks after their initiation. The majority of these medications were developed for other indications; however, they were found to be highly beneficial for individuals with migraines and other headache types. The selection of the medication depends on the medication’s potential side effect profile, and the patient’s comorbidities.
Commonly used prescription prophylactic medications include:
1) Antihypertensives are medications commonly used to lower blood pressure, but have been found to also have headache prophylaxis effects. These include beta blockers such as Inderal (propranolol), Lopressor and Toprol (metoprolol), and Tenormin (atenolol); and calcium channel blockers like Calan (verapamil), and Norvasc (amlodipine). The calcium channel blockers can be effective for cluster headaches.
2) Antidepressants, including the tricyclics Elavil (amitriptyline), and Pamelor (nortriptyline); selective serotonergic reuptake inhibitors (SSRI) such as Zoloft (sertraline), Proxac (fluoxetine), Paxil (paroxetine); and serotonin/ norepinephrine reuptake inhibitors (SNRI) Cymbalta (duloxetine) and Effexor (venlafaxine). These medications can be helpful in patients with comorbid depression or anxiety (without mania); the tricyclics may be beneficial in patients with comorbid insomnia; tricyclics and duloxetine may beneficial in patients with other comorbid pain issues.
3) Antiepileptic medications are used to prevent seizures, and some have been found to help reduce headache frequency and severity. Those used for prophylaxis against headaches include: valproic acid, Neurontin (gabapentin) and Topamax (topiramate). The use of valproic acid is limited due to potential facial hair growth in women, weight gain and decreased bone density leading to osteoporosis or osteopenia. Gabapentin may be useful for other comorbid pain but can have associated weight gain and peripheral swelling. Topiramate when used in high doses may be effective in cluster headaches, but may have associated appetite suppression, and gradual weight loss. Topiramate can also have associated paresthesias, cognitive impairment, risk of kidney stones and glaucoma, alteration of taste, and decreasing effectiveness of oral birth control.
4) Botox (Botulinum toxin) treatment for headache prophylaxis consists of 31 injections across the forehead, temples, posterior head and neck and shoulder regions which are repeated every 90 days. This treatment is limited by insurance coverage requirements to headaches of four or more hours duration, monthly the headaches must occur more than fifty percent of the days, and there is documented failures of several other prophylactic treatments. Potential risks include temporary paralysis of muscles in the injected area, eyelid droop, severe difficulty speaking, or respiratory compromise. Botox is contraindicated in patients with neuromuscular disease, motor neuron disease or infection in the area to be injected.
5) Calcitonin gene-related peptide (cGRP) receptor blocker, including Aimovig (erenumab-aooe) and Ajovy (fremanezumab-vfrm), just to name a few. cGRP blockers are administered by monthly subcutaneous injections. They are very well tolerated with few side effects outside of potential injection site irritation. Insurance coverage could also be limited to headaches of four or more hours duration, monthly the headaches must occur more than fifty percent of the days, and there is documented failures of several other prophylactic treatments.
Prophylaxis selection can be greatly limited during pregnancy, as most of these medications have been designated as Class C or Class D pregnancy risk. Most obstetricians in our area have recommended against use of these medications for women who are pregnant, or are considering pregnancy.
Lastly, nonprescription medications may also provide benefit to some. The following over-the-counter medications have been shown to be effective in some individuals: magnesium, vitamin B2 (riboflavin), melatonin (10-12 mg at bedtime), butterbur 75 mg twice a day, CoQ10 and feverfew. Non-pharmacologic interventions which may provide some benefit include sufficient restorative sleep, stress reduction, compresses, distraction therapy, physical therapy, massage therapy and acupuncture.
V. When should one see a neurologist for their migraines and headaches?
Most individuals with more than 2-3 headaches per month are successfully managed with abortives and prophylaxis. If the evaluation and management results are suboptimal, or beyond the prescribing comfort level of the physician, then considering a referral to a neurologist is appropriate. The vast majority of headaches can be well-managed by a general neurologist.
Any time someone develops sudden onset of the worse headache of his/her life (e.g., thunderclap headache) or a headache with associated slurred speech, language or coordination impairment, unilateral weakness or sensory loss then immediate medical intervention is highly advisable in order to evaluate for potentially life-threatening processes such as an intracranial hemorrhage or ischemic stroke.