How are migraine headaches treated?

Nonmedication therapies for migraine

Therapy that does not involve medications can provide symptomatic and preventative therapy.

• Using ice, biofeedback, and relaxation techniques may be helpful in stopping an attack once it has started.
• Sleep may be the best medicine, if it is possible.

Prevention of migraine requires motivation by the patient to make some life changes. Patients are educated as to triggering factors that can be avoided. These triggers include:

• smoking, and
• avoiding certain foods, especially those high in tyramine such as sharp cheeses or those containing sulfites (wines) or nitrates (nuts, pressed meats).

Generally, leading a healthy lifestyle with good nutrition, an adequate intake of fluids, sufficient sleep, and exercise may be useful. Acupuncture has also been suggested to be a useful therapy.

Medication for migraine

Individuals with occasional, mild migraine headaches that do not interfere with daily activities usually medicate themselves with over-the-counter (OTC or nonprescription) pain relievers (analgesics). Many OTC analgesics are available. OTC analgesics have been shown to be safe and effective for short-term relief of headache (as well as muscle aches, pains, menstrual cramps, and fever) when used according to the instructions on their labels.

There are two major classes of OTC analgesics:

• acetaminophen (Tylenol) and
• nonsteroidal anti-inflammatory drugs (NSAIDs).

Acetaminophen

Acetaminophen reduces pain and fever by acting on pain centers in the brain. Acetaminophen is well tolerated and generally is considered easier on the stomach than NSAIDs. However, acetaminophen can cause severe liverdamage in high doses or if used on a regular basis over extended periods of time. In individuals who regularly consume moderate or large amounts of alcohol, acetaminophen can cause serious liver damage at lower doses that are not usually toxic. Acetaminophen also can damage the kidneys when taken in large doses. Therefore, acetaminophen should not be taken more frequently or in larger doses than recommended on the package label.

NSAIDS

The two types of NSAIDs are 1) aspirin and 2) non-aspirin.

Examples of non-aspirin NSAIDs are ibuprofen (Advil, Nuprin, Motrin IB, and Medipren) and naproxen (Aleve). Some NSAIDs are available by prescription only. Prescription NSAIDs are usually prescribed to treatarthritis and other inflammatory conditions such as bursitis, tendonitis, etc. The difference between OTC and prescription NSAIDs usually is the amount of the active ingredient contained in each pill. For example, OTC naproxen (Aleve) contains 220 mg of naproxen per pill, whereas prescription naproxen (Naprosyn) contains 375 or 500 mg of naproxen per pill.

NSAIDs relieve pain by reducing the inflammation that occurs during the headache (They are called nonsteroidal antiinflammatory drugs or NSAIDs because they are different from steroids such as prednisone, prednisolone, and cortisone which also reduce inflammation). Steroids, though valuable in reducing inflammation, have predictable and potentially serious side effects, especially when used long term. Their full effects also require hours or days. NSAIDs do not have the same side effects that steroids have, and their onset of action is faster.

Aspirin, Aleve, Motrin, and Advil all are NSAIDs and are similarly effective in relieving pain and fever. The main difference between aspirin and non-aspirin NSAIDs is their effect on platelets, the small particles in blood that cause blood clots to form. Aspirin prevents the platelets from forming blood clots. Therefore, aspirin can increase bleeding by preventing blood from clotting though it also can be used therapeutically to prevent clots from causing heart attacks and strokes. The non-aspirin NSAIDs also have antiplatelet effects, but their antiplatelet action does not last as long as aspirin (hours rather than days).

Aspirin, acetaminophen, and caffeine also are available combined in OTC analgesics for the treatment of headaches including migraine. Examples of such combination analgesics are Pain-aid, Excedrin, Fioricet, and Fiorinal.

Finding an effective analgesic or analgesic combination often is a process of trial and error because individuals respond differently to different analgesics. In general, a person should use the analgesic that has worked in the past. This will increase the likelihood that an analgesic will be effective and decrease the risk of side effects.

There are several precautions that should be observed with OTC analgesics:

• Children and teenagers should not use aspirin for the treatment of headaches, other pain, or fever, because of the risk of developing Reye syndrome, a life-threatening neurological disease that can lead tocoma and even death.
• People with balance disorders or hearing difficulties should avoid using aspirin because aspirin may aggravate these conditions.
• People taking blood thinners such as warfarin (Coumadin) should not take aspirin and non-aspirin NSAIDs without a doctor's supervision because they increase the risk of bleeding that is caused by the blood thinner.
• People with active ulcers of the stomach and duodenum should not take aspirin and non-aspirin NSAIDs because they can increase the risk of bleeding from the ulcer and impair healing of the ulcer.
• People with advanced liver disease should not take aspirin and non-aspirin NSAIDs because they may impair kidney function. Deterioration of kidney function in these patients can lead to failure of the kidneys.
• OTC or prescription analgesics should not be overused. Overuse of analgesics can lead to the development of tolerance (increasing ineffectiveness of the analgesic) and rebound headaches (return of the headache as soon as the effect of the analgesic wears off, usually in the early morning hours). Thus, overuse of analgesics can lead to a vicious cycle of more and more analgesics for headaches that respond less and less to treatment.