Harvard Women's Health Watch

New ways to manage migraines

Sufferers now have more options than ever to ease the pain or even ward off attacks.

If you’ve ever experienced a migraine, you know it’s no ordinary headache. Not only does it cause throbbing pain, typically on one side of your head, but it may also cause vision changes, sensitivity to light, and nausea. It’s the type of headache that makes you want to retreat to a dark, quiet room and stay there until it goes away. Recovering from a migraine can take time; the headache can last for hours or days. Migraines affect an estimated 28 million women in the United States, according to the American Migraine Foundation (AMF).

The World Health Organization says that migraine headaches rank in the top 10 of disabling conditions. These headaches result in lost work days, lost productivity, and high health care costs. And of course, they can cause you to miss out on pleasurable activities and time with family.

But compared with years past, there are more options than ever for treating these headaches.

Are my headaches a problem?

“Many women suffering with regular migraines don’t seek treatment. They may feel like it’s just something they need to put up with or they don’t require treatment because they don’t have headaches every day,” says Dr. Elizabeth Loder, professor of neurology at Harvard Medical School and chief of the Division of Headache and Pain in the Department of Neurology at Brigham and Women’s Faulkner Hospital. “Women say to me: ‘I’m sorry, I know other people are worse off.’”

But if migraine headaches are interfering with your life, causing you to miss out on work or leisure activities, it’s definitely worth having them checked out. “Frequently there are things we can do to help,” she says.

Is it really a migraine?

The first step in treating migraine headaches is diagnosing them.

Doctors rely on widely accepted diagnostic criteria to differentiate between migraine headaches and other types of headache. In order to qualify as a migraine, the headache must last between four and 72 hours. It’s typically on one side of the head. It’s often throbbing or pounding, with moderate to severe pain that gets worse with physical activity. “A person must experience at least five attacks that meet most or all of these criteria in order to be diagnosed with migraine,” says Dr. Loder.

If your doctor suspects that you are experiencing migraines, treatment will typically be based on the frequency of your symptoms.

In some cases, changes in hormones trigger headaches. Some women notice headache patterns that coincide with monthly hormone fluctuations or the hormone shifts that accompany menopause.

“Progress in treating migraines has been occurring, although maybe not as quickly as we would like,” says Dr. Loder. Even so, there are numerous options. Treatments fall into two categories: those that address the headache when you get one, and those that attempt to prevent the migraine headache from happening in the first place.

Migraines with aura may raise special considerations

Some 15% to 30% of migraine sufferers experience an aura before the headache hits. An aura is a neurological event, typically a visual disturbance such as a pulsing or flashing light, blurriness, or even partial loss of vision. Research has linked this type of migraine headache with a specific heart defect, patent foramen ovale (PFO), which is essentially a hole in the tissue separating the two upper chambers of the heart. The hole is ­normal in the developing fetus and typically seals itself at birth, but in some individuals, it remains open. Some 40% to 60% of people who have migraines accompanied by an aura have a PFO, according to the American Headache Society. It’s not clear if the PFO causes the migraines or if people with this type of migraine are, for some other reason, just more likely to have both conditions.

If this heart defect is present, you don’t necessarily need to do anything to repair it, because clinical trials have shown that a surgical fix does not appear to offer any advantage with regard to migraines, says Dr. Elizabeth Loder, professor of neurology at Harvard Medical School. However, there is one precaution women with this type of migraine should take, says Dr. Loder. Researchers have found that people who experience migraines with aura are at slightly higher risk for stroke. For this reason, women with the condition should be cautious about using estrogen-containing birth control pills or estrogen therapy after menopause, either of which also increases the risk of stroke, says Dr. Loder.

Relieving pain

If you experience migraines only occasionally, over-the-counter medications such as aspirin, with or without caffeine, may be a good way to relieve the pain. But beware of rebound headaches that can result from using pain-relieving medications too frequently.

However, if your headaches are more frequent or severe, you may want to talk to your doctor about a preventive approach (see below) as well as prescription medication to treat individual attacks.

Drugs in a class known as triptans are commonly prescribed to treat individual attacks.

Triptans, which are available as tablets, nasal sprays, or injections, work by stimulating your brain to produce serotonin, a neurotransmitter (chemical messenger) that works in your brain. The serotonin helps reduce inflammation and constrict blood vessels in your brain, according to the National Headache Foundation, bringing you relief from the pain. Most people get relief from pain within two hours of taking the medication. Others may need another dose.

“Triptan medications used to be very expensive, but the availability of generic versions has brought prices down. They work very well for 70% to 80% of people,” says Dr. Loder.

However, some individuals are unable to take triptans because of the drugs’ side effects or because they have certain health conditions, such as heart disease. Triptans can affect blood flow not only to your head, but also to your heart, which is why they pose risks for patients with coronary artery disease or risk factors for this condition.

Can lifestyle changes prevent migraines?

Making some lifestyle changes can help reduce migraines in some individuals. To begin with, “people can identify things that make it more likely that they will have a headache,” says Dr. Elizabeth Loder, professor of neurology at Harvard Medical School.

For some people, migraines are triggered by caffeine withdrawal or alcohol use. While doctors used to think that food triggers played a big role in migraine headaches, there are no good data to support this view.

In addition to identifying potential headache triggers, you may also be able to reduce the likelihood of a migraine by eating regular meals and following other good health habits, such as getting enough sleep and managing stress.

But keep in mind, even the most diligent lifestyle efforts may not prevent all migraines.

An ounce of prevention

The other category of migraine treatments includes those designed to prevent migraines. These include pills, injections, and making behavioral changes (See above, “Can lifestyle changes prevent migraines?).

These treatments are primarily reserved for people with frequent or chronic migraine headaches.

Some relatively new options have been added to your doctor’s arsenal in recent years to help head off these headaches before they start. These include

Botulinum toxin injections. One treatment that was approved in 2010 for people with chronic migraines is onabotulinum toxin A, best known by the brand name Botox as a cosmetic treatment for smoothing wrinkles. Injecting this drug into the scalp and neck is thought to block pain transmission and has proved effective in preventing migraines in some people. In order for this approach to work, you will need to get multiple treatments over time. A single treatment typically lasts between 10 and 12 weeks, according to the AMF.

Oral medications. In 2018, a new category of medications, known as anti-CGRP antibodies, is expected to hit the market. These drugs counteract the effect of calcitonin gene-related peptide (CGRP), a chemical your body naturally produces that, among other things, causes blood vessels to dilate. Similar antibody treatments have been used for rheumatological disorders or neurological diseases such as multiple sclerosis. These new anti-CGRP antibodies have shown some benefit for preventing migraines, says Dr. Loder. “In clinical trials they seem to be more effective than placebo,” she says. While they don’t appear to be more effective than current medications, they may give women who haven’t responded well to other medications a new option to try, and they may have fewer side effects than other treatments. However, their long-term safety has yet to be determined. “It will be interesting to see how they fit in with the existing treatments,” says Dr. Loder.

With luck, more treatments will be available in the future. In the meantime, if you do suffer from migraine headaches, discuss your migraines with our doctor. Keep in mind that your doctor may need to try different combinations of medication in order to find the right approach for your unique needs.

Used alone or in combination, today’s treatment options can help you get relief for what can be a debilitating, painful condition.

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