Complete Treatment Guide for Migraine Headache

This Article Discuss About:

Preventive Medications for Migraine Headache:

  • Beta-Blocker: Inderal for relaxing blood vessels.
  • Calcium-channel blocker: Cardizem, vasodilator which helps in relaxing blood vessels.
  • Tricyclic Antidepressant: Amitriptyline.
  • Anticonvulsant: Depakote.

Therapeutic Medications for Migraine Headache:

  1. Triptans for Migraine Headache

    Complete Treatment Guide for Migraine Headache:

    Triptans are prescribed for migraine and cluster headache. Triptan can be given as nasal sprays or intravenously. Sumatriptan injections are very effective for treatment of cluster headaches and start to kick in less than 15 minutes. Nasal route of Sumatriptan is effective in 30 minutes. In majority of cases, effectiveness of nasal treatment reduces within 45 minutes. Pain relief tends to be much better with intravenous treatments than nasal sprays. Newer Triptans with fewer side effects used are Zolmitriptan (Zomig) in oral or nasal spray forms.

    Side Effects of Sumatriptan Are:

    • Nausea
    • Dizziness
    • Muscle weakness
    • Heaviness or pressure in the chest
    • Tingling and numbness in the toes
    • Rapid heart rate

    Complications Involving Sumatriptan For Treating Migraine Headache:

    • Stroke: Secondary to vasoconstriction of cerebral arterial blood vessels.
    • Heart attack and Angina : Secondary to vasoconstriction of coronary artery.
    • Hypertension : Caused by vasoconstriction of peripheral arterial system.
    • Serotonin Syndrome: This is a life-threatening condition. Sumatriptan increases overall concentration of serotonin in brain. Symptoms observed are tachycardia, nausea, vomiting, diarrhea, hallucination, anxiety, tremors and restlessness.
  2. Ergotamine for Migraine Headache

    Dehydroergotamine (DHE) is prescribed for migraine headache. Most of the patients respond within 5 minutes with no pain. Ergotamine can be prescribed as tablets, suppositories and nasal spray.

    Side Effects of Ergotamine:

    • Tachycardia
    • Nausea and vomiting
    • Diarrhea
    • Dizziness
    • Muscle weakness
    • Heaviness or pressure in the chest
    • Tingling and numbness in the toes

    Complications Involving Ergotamine In Treating Migraine Headache:

    • Stroke: Secondary to vasoconstriction of cerebral arterial blood vessels.
    • Heart Attack and Angina: Secondary to vasoconstriction of coronary artery.
    • Hypertension - Cause by vasoconstriction of peripheral arterial system.
    • Serotonin syndrome is a life-threatening condition but less severe than Triptans. Sumatriptan increases overall concentration of serotonin in brain. Symptoms observed are tachycardia, nausea, vomiting, diarrhea, hallucination, anxiety, tremors and restlessness.
  3. Capsicum For Treating Migraine Headache

    Capsicum originates from hot pepper. It is used in tension and cluster headache. Capsicum is applied over occipital skin and also inside nose. It is a safe medication and available as over the counter product in pharmacy.

    Side Effects of Capsicum:

    • Burning sensation over skin and nose.
    • Sneezing and watery eyes.
    • Stomach Upset
    • Sweating
    • Flushing and running nose
    • Dermatitis

    Serious Side Effects of Capsicum:

    • Liver and kidney damage
    • Stop using 2 weeks before surgery as it may cause side effects of bleeding.
  4. Calcium Channel Blockers To Treat Migraine Headache:

    Calcium channel blockers influences the calcium channel of smooth muscle of the blood vessels. Calcium channel blocker is effective in treating hypertension and coronary vascular disease. Migraine and cluster headache is secondary to changes in diameter of cerebral blood vessels. Calcium channel blocker causes changes in diameter of cerebral blood vessel resulting in reduction of headache symptoms. Verapamil is a preferred calcium channel blocker used for preventive treatment of cluster and migraine headache. Medication should be taken for 2 to 3 weeks to build maximum effects.

    Side Effect of Calcium Channel Blocker:

    • Constipation
    • Severe Hypertension : If discontinued abruptly
    • Bradycardia and Hypertension : If overdosed
    • Heart Failure : History of congestive heart failure.
  5. Lithium For Migraine Headache

    Lithium (Eskalith, Lithane, Lithobid, Lethonate, Lithotabs), commonly used for bipolar disorder, may also help prevent cluster headaches or migraine headache. The patient usually receives benefit within 2 weeks of starting to take the drug, and often within the first week. Lithium may be used alone or with other drugs. Lithium can have many side effects including trembling of hands, nausea, and increased thirst. Weight gain is a common side effect with long-term use.

    Side Effects Of Lithium:

    • Thinning of the hair and hair loss,
    • Mild tremor,
    • Loss of appetite,
    • Tiredness,
    • Nausea.

    Severe Allergic Reactions Of Lithium:

    • Skin : Rash, hives, itching.
    • Respiratory System : Bronchospasm, dyspnea and tightness in the chest.
    • Cardiovascular System : Slow or irregular heartbeat;
    • Central Nervous System : Confusion, restlessness, tremor, dizziness, faintness, bladder and bowel incontinence, numbness of skin, ringing in the ear, restlessness, seizures and severe or persistent headache.
    • Musculoskeletal System : Tremors, involuntary muscle twitching, decreased muscle tone and coordination.
    • Gastrointestinal System : Edema of oral cavity and tongue, nausea and diarrhea,
  6. Anti-Seizure Medications For Migraine Headache:

    Anti-seizure medications are thought to reduce the occurrence of migraines by calming inflamed blood vessels in the brain, which may lead to migraine pain. However, none of these medications is a cure for migraines. Antiepileptics are diverse group of medications used as antiseizures. Some of the medication within this large group has been used to treat headache. In research there were areas of hyperactivities in brain which were recognized in epilepsy and headache patients. Antiepileptic medications reduced area of irritability by its molecular action at voltage gated sodium channel. Most common used antiepileptic in headache treatment is Topamax, Depakote and Neurontin.

  7. Topamax For Migraine Headache

    Oral tablet is taken everyday as prescribed even if headache symptoms are absent.

    Side Effects of Topamax :

    • Tachycardia
    • Dyspnea - Breathlessness or shortness of breath, Chest pain,
    • Urine - Bloody or cloudy
    • Cognitive Symptoms - Thoughts of suicide or aggressive behavior Depression
  8. Depakote For Migraine Headache

    Depakote (valproic acid) is available as capsule, tablet and syrup.

    Side Effects Of Depakote:

    • Liver damage
    • Pancreatitis
  9. Neurontin For Migraine Headache:

    (Gabapentin) used in post-herpetic neuralgia, diabetic neuropathy and fibromyalgia.

    Side Effects of Neurontin:

    • Nausea

    Serious Allergic Reaction of Neurontin :

    • Skin : Rash, hives, itching.
    • Respiratory System : Bronchospasm, dyspnea and tightness in the chest.
    • Central Nervous System : Seizures and tremors
    • Musculoskeletal System : Tremors.
  10. Corticosteroids For Migraine Headaches:

    Corticosteroid drugs (also called steroids) are used in allergic reaction and autoimmune disease as anti-inflammatory medications. Corticosteroids are membrane stabilizing agents, prescribed for headache to prevent irritability of cortical and subcortical centers. It enhances the effect of verapamil in treatment of headache and often prescribed with verapamil. Prednisone has been tried as short-term breakthrough pain meds for cluster headache. It is often prescribed as tablet form prednisone and injection form decadron.

    Side Effects of Corticosteroids:

    • Symptoms like Diabetes : Increased blood sugar level
    • General Symptoms : Dry mouth, fatigue, weakness, blurred vision, facial swelling, infection, avascular necrosis and glaucoma
    • Central Nervous System : Anxious, depression, confusion, insomnia, mania, and psychosis.
    • Gastrointestinal System : Stomach bloating feeling, increased appetite, weight gain, abdominal pain, diarrhea and peptic ulcer.
    • Urination : Frequent urination.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) For Migraine Headache:

NSAIDS are anti-inflammatory medication abbreviated as NSAIDs. NSAIDs are used for treatment of headache in combination with other medications. Mild headaches are often treated by NSAIDs alone.

Analgesics: NSAIDs are not effective in severe pain and also pain caused by non-inflammatory etiology.

Most Prescribed NSAIDs: Aspirin, ibuprofen (Motrin, Advil) and naproxen (Aleve).

Side Effects of NSAIDS: Complications caused by NSAIDs can be devastating if continued for prolonged period of time.

Dose Dependent Side Effects: Dyspepsia, ulcer, perforation, upper gastrointestinal bleeding and severe blood loss. Combination of aspirin and COX 2 inhibitor (Celebrex) may block cardio-protective effects of aspirin.

  • Myocardial Infarction and Stroke - NSAIDs with COX2 inhibitor may increase risk. Combination of NSADs and COX 2 are not recommended in-patient with history of myocardial infarction and heart attack.
  • Erectile Dysfunction.

NSAIDs combinations with other medications used in headache. Most acute attacks of tension-type headaches get better without any treatment. Over-the-counter pain relievers such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) can treat mild symptoms. Aspirin or ibuprofen (generic, Advil, other brands) is usually the first choices, followed by naproxen (generic, Aleve). Some patients may also find helpful medications that combine a pain reliever with caffeine.

  • Ibuprofen (Advil, Motrin)
  • Naproxene (Aleve, Napralan, Naprosyn, Anaprox), Acetaminophen/butalbital (Bupap, Cephaldine, Phrenllin)
  • Acetaminophen/butalbital/caffeine (Esgic, Fioricet), Aspirin/butalbital/caffeine (Fiorinal),
  • Acetaminophen/butalbital/caffeine/codeine (Fioricet with codeine),
  • Acetaminophen/dichoraphenazone/sometheptene mucate (Midrin),
  • Acetaminophen phenyltolaxamine (Percogesic)
  • Acetaminophen/isometheptene mucate (Prodrin)

Anti-anxiety Medications For Treating Migraine Headache:

Sedatives are used in treatment of headache. Most common indication to use sedatives or anti anxiety medications are Tension headache and prevent recurrent episode. Buspirone (Buspar) and Alprazolam are prescribed as antianxiety medications.

Side Effects of Anti-anxiety Medication:

  • Drowsiness, irritability,
  • Fatigue
  • Low blood pressure
  • Amnesia

Opioid Medications To Treat Migraine Headache

Opioids are used for treating migraine headaches, which are not responding to NSAIDS and other medications. Acute and brief attack of headache most of the time gets better without any treatment. Patients may develop resistance and tolerance to opioid medication. Patients are advised relaxation treatment, cognitive behavioral therapy and lifestyle changes if failed to get pain relief with opioids. Daily attack of headaches are treated with preventive medication such as NSADs, NSAIDs combined with opioids. All other options of medications should be tried before introducing opioid medications. Patient dependent on opioids for pain relief at time may behave like drug addict. Opioid dependence some time needs higher dosage and frequent need of pain medications. These symptoms are because of opioid dependence to achieve pain relief and classified as Pseudoaddiction. Opioids do cause addiction in few patients and treatment of headache with opioids become difficult.

Side Effects of Opioids:

  • Common Side Effects Of Opioids : Nausea, Vomiting, Constipation, Dry mouth, Itching and Miosis.

Less Common Side Effects Of Opioids:

  • Skin : Itching, urticarial, hypothermia and histamine induced flushing
  • Eyes : Miosis
  • Gastrointestinal : Nausea, vomiting, dry mouth, constipation and biliary spasm (colicky pain)
  • CNS : Depression, confusion, hallucination, delirium and dizziness
  • Respiratory System : Depression
  • CVS : Bradycardia and occasional may be tachycardia, Orthostatic hypotension, Kidney
  • Ureter and Bladder (KUB) : Urinary retention and ureteric spasm
  • Musculoskeletal : Muscle spasm.
  1. Semisynthetic Derivatives: Hydrocodone, Hydromorphone, Oxycodone, Oxymorphone Diacetylmorphine (heroin), Dihydrocodeine, Nicomorphine
  2. Synthetic Opioids :
    1. Anilidopiperidines : Fentanyl, Sufentanil, Alfentanil, Remifentanil and Carfentanil
    2. Phenylpiperidines : Meperidine, Allyprodine and Ketobemidone.
    3. Diphenylpropylamine derivatives : Propxyphene, Dextromoramide, Methadone, Piritramide, Dipipanone, Difenoxin, Diphenoxylate and Loperamide
    4. Benzomorphan Derivatives : Pentazocine, Phenazocine and Dezocine
    5. Oripavine Derivatives : Buprenorphine and Etorphine
    6. Morphinan Derivatives : Butorphanol, Levomethorphan, Nalbuphine and Levorphanol
    7. Others : Tramadol, Tapentadol, Meptazinol

Botox Treatment for Migraine Headaches:

Botulinum toxin A (Botox) injections are typically used to smooth wrinkles in practice of plastic surgery. Botox is also being studied for treatment of headaches, including the prevention of cluster headaches. Research is still preliminary and there is not sufficient evidence to support its efficacy. Botox is treatment of choice for headache localized over frontal, occipital and cervical (neck) region. Headache over parietal (top of head), temporal area (side of head above ear), between eyes and behind ear does not respond to botox injection.

Frequent Common Side Effects of Migraine Headache:

  • General Symptoms: Irritated eyes, facial pain, flu-like symptoms, inability to focus the eyes, neck pain, redness, swelling, tenderness at the injection site; sensitivity to light, sweating and tiredness.
  • CNS: Anxiety, arm or leg pain, back pain, dizziness, drowsiness and headache.
  • Gastrointestinal System: Nausea, constipation, dry mouth, dry and indigestion.
  • Respiratory System: Increased cough, mild sore throat and runny nose.
  • Musculoskeletal: Stiff or weak muscles at or near the injection site.
  • Severe allergic reactions need immediate medical attention.
  • Skin : Swelling of the mouth, face, lips, or tongue fever and chills.
  • Respiratory System: Unusual hoarseness, wheezing, chest pain, difficulty swallowing or breathing, persistent sore throat and shortness of breath.
  • Kidney Ureter Bladder : Blood in the urine; burning, numbness or tingling; burning with urination; difficult, frequent, or painful urination, loss of bladder control, eyes-double or blurred vision, or other vision changes; drooping of the upper eyelid and eyelid swelling.
  • Central Nervous System: Fainting; seizures, headache, dizziness speech changes or problems and worsening migraine.
  • Cardiovascular System: Irregular heartbeat.
  • Musculoskeletal System: Loss of strength, paralysis and severe or persistent muscle weakness.

Melatonins (N-acetyl-5-methoxytryptamine): Melatonin is found in animals, plants, and microbes. Melatonin sold over the counter in USA. In animal research melatonin was investigated against carcinogens. Melatonin prevents initiation of impairment of DNA by carcinogens. Impaired DNA otherwise would have initiated cancer growth.

Melatonin has been prescribed for headache and several other diseases. Melatonin is widely used as an antioxidant in diseases such as immunodeficiency syndrome, autism, aging, Alzheimer disease, delirium mood disorder, alternative medicine, tinnitus, cancer and gallstone.

Oxygen Therapy for Migraine Headache

Oxygen percentage in atmosphere is 21%. Oxygen therapy can provide from 30% to 100% oxygen. Nasal oxygen therapy using nasal cannula provides 30 to 40% oxygen. Tight fitting facemask or endotracheal tube can deliver up to 100% oxygen. Oxygen therapy has been used in congestive heart failure, chronic obstructive lung disease (COPD), and allergic reaction causing shortness of breath, convulsion and hemorrhagic shock. Oxygen therapy up to 100% is used in cluster and tension headache on and often. Patient is advised to inhale oxygen for 15 minutes several times a day.

Surgery for Migraine Headache

Muscle Pressure Release and Repositioning Nerves: Several surgical options were tried during last few years. Most accepted surgery is to release the pressure over the nerves causing frontal, temporal or occipital neuralgic migraine headache. Some of the peripheral branches of cranial and cervical nerves passes through the muscles and pressure or pinch of these nerves causes neuralgic migraine headache. A neurologist confirms a diagnosis of migraine by CT scan and diagnostic botox injection. In addition nerve block is also performed using local anesthetics and corticosteroids. Specific contact points to generate neurogenic pain trigger peripheral branches of cranial and cervical sensory nerves of frontal, temporal and occipital dermatome. Trigger site is almost always the contact site where nerve pierces the muscles. Pressure over nerve causes nerve irritation and retrograde activation of inflammation of meningeal layers. Meningeal inflammations triggers migraine headache.

Nerve Passing Through Muscles:

  • Greater Occipital Nerve- Semispinalis capitus muscles.
  • Zygomatigotemporal Nerve- Temporalis muscles.
  • Supraornital and Supratrochlear Muscles- Glabellar muscle, group corrugator supercilli, depressor supercilli and procerus muscles

Migraine Headache:

  • Forehead Migraine Headaches- Supra-orbital and supra trochlear nerves.
  • Temporal Migraine Headaches- Zygomatigotemporal branch of trigeminal nerve
  • Occipital Migraine Headache- Greater occipital nerve.

Surgery involves separation of nerves from muscles and repositioning of muscles. After separation, nerves are covered with subcutaneous fatty tissue. Occasional cosmetic surgery is performed to prevent external pressure and correct surgical complications.

No serious complications were reported and side effects for some included occasional neck stiffness and skin numbness.

Vascular Pressure Release: Terminal branches of external carotid artery are ligated or cauterized. In few cases cryotherapy is used to freeze the branches. Headache is presented with aura and pressure over the most painful site reduces pain.

Brain and Nerve Stimulator to Treat Migraine Headache

Chronic cluster and migraine headaches in few patients are resistant to all treatments. These patients are imprisoned in house suffering with intense headache and unable to perform any kind of regular activities. Intense pain may bring multiple thoughts of suicide. These patients are given a trial of stimulator as a last option of treatment. Stimulator is placed over brain, vagus nerve or occipital nerve. Pain when predominantly is located over occipital dermatome then occipital nerve stimulation will be treatment of choice. Cluster headache is treated with placement of stimulator over cerebral cortex, hypothalamus and vagus nerve. These treatments are considered experimental in United States.

Facial Nerve Ablation To Treat Migraine Headache

Migraine headache associated with facial nerve involvement is treated with gasserian ganglion neurotomy using either radiofrequency heat or chemical neurotomy using glycerol. Percutaneous radiofrequency gasserian ganglion rhizotomy is the treatment that involves destruction of pain fibers in gasserian ganglion by heat from radiofrequency. Pain carrying fibers are also often destroyed in few cases using glycerol as a chemical rhizotomy.

Micro Vascular Decompression of Trigeminal Nerve- Treatment is advised if migraine headache is associated with post herpetic trigeminal neuralgic pain. Trigeminal nerve pain is seen after post herpetic neuralgia and traumatic injury of trigeminal nerve. Chronic headache pain secondary to trigeminal neuralgia is treated with microvascular decompression of trigeminal nerve. Blood vessels surrounding trigeminal nerve are selectively ligated or cauterized to eliminate the pressure.

Cognitive Behavioral Treatment For Migraine Headache

Cognitive Behavior Therapy (CBT) is useful to assist change or modify behavior problems in-patient suffering with chronic headache.

  • Undesired Behaviour: Try eliminating and reinforce the changed behavior.
  • Mode of Various Therapies: Individuals and groups suffering with cluster headache and migraine.
  • Therapy as a Treatment: CBT has also been used in organic disorder such as headache primary and secondary causing severe pain not responding to any treatment. Also very effective in patient suffering with headache and insomnia. Integration of behavioral therapy with cognitive therapy. Maladaptive thinking leads to change in affect and thus behavior.
  • Computer based supervised therapy
  • Goal to change maladaptive thinking.

Principle of Treatment:

  • Points out over generalizing of symptoms
  • Magnifying negative feelings
  • Minimizing positive thoughts
  • Guiding to more realistic effective concepts
  • Assess, reconceptualized and acquisition of positive skills

Treatment Orientation:

  • Cognitively oriented.
  • Behaviorally oriented.
  • Imaginary exposure therapy combines both approaches.
  • Systemic Desensitization: Systematic desensitization involves gradually exposing a patient to anxiety-provoking stimuli until the anxiety response was extinguished or eliminated.
  • Positive Reinforcement or Reward: This improves behavior when compared with conditioning such as repetition of harmful behavior was punished and improvement in behavior was rewarded.

Behavioral Therapies for Migraine Headache

Behavioral therapies can be a helpful accompaniment to drug treatment. These approaches can help with pain management and enable patients to feel more in control of their condition.

Behavioral Approaches Include:

  • Relaxation treatment combined with biofeedback.
  • Cognitive-behavioral therapy.

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: October 13, 2014

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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