Effective management and treatment of chronic Migraine (CM) is multi-faceted. Medications alone are not adequate management. Other elements of management that should be incorporated include:
- education – learning about the Migraine disease in general and the specific type(s) of Migraines we have;
- trigger identification and management;
- treating any comorbid disorders that might impact Migraines and / or their treatment – including depression, anxiety, and other mental health disorders as well as physical conditions;
Medications for chronic Migraine (CM) falls into the same three categories as treatment for episodic Migraine:
The primary goals of preventive treatment are:
- reducing both the frequency and severity of Migraine attacks,
- reducing our need for acute medications taken when a Migraine occurs, and
- improving quality of life.
At this time, there are no medications available that were specifically developed for Migraine prevention. There are over 100 medications in use for Migraine prevention, for both episodic and chronic Migraine, but all of them were originally developed for other conditions, then observed to be helpful in treating Migraine. Four medications have been approved by the FDA for Migraine prevention:
- propranolol (Inderal),
- timolol (Blocadren),
- divalproex (Depakote), and
- topiramate (Topamax).
In addition, onabotulinumtoxin type A (Botox) has been approved by the FDA for the treatment of chronic Migraine.
Other medications used for Migraine prevention are prescribed off-label. Off-label prescribing is quite common and is when doctors prescribe medications for conditions other than those for which they’re FDA approved. Determining which preventive medications will work for individual Migraineurs is difficult and is often a matter of trial-and-error and patience. When determining which preventive medications to try for CM, there are fewer studies to review since most of these studies have excluded people with CM. However, some studies have shown sodium valproate (Depakote), topiramate (Topamax), and onabotulinumtoxin type A (Botox) to be effective for CM. This is no guarantee that any of these three medications will work for a particular patient, but may at least offer a good starting point. Another issue to consider is that both topiramate and onabotulinumtoxin type A have been shown to be effective for some Migraineurs regardless of their being in a period of medication overuse headache.
Abortive treatment is used when a Migraine occurs and is intended to stop the Migrainous process in the brain, which will also stop the Migraine symptoms. Abortive treatment is generally considered preferable to using pain medications because they can only mask the pain for a few hours, not actually stop the Migraine. It’s not unusual for antinausea medications to be used in conjunction with abortive medications when nausea is severe.
Abortive medications include the triptans (Imitrex, Maxalt, Zomig, etc.) and some ergotamine medications (D.H.E. 45, Migranal Nasal Spray). You can find more information on abortive treatment in Migraine Management Essential 5: Abortive Treatment.
Rescue medications are those used to treat Migraine attacks when abortive medications have failed or cannot be used. Rescue treatment may be one medication or a combination of medications. The primary goal of these medications is to give us relief from the headache and other symptoms of the Migraine until the attack ends. Another goal of rescue medications is to give us as many options as possible for treating Migraine at home and not having to utilize the emergency room for Migraine attacks. You can find more information on rescue treatment in Migraine Management Essential 6: Rescue Treatment.
Chronic Migraine and medication overuse headache
A major consideration with abortive and rescue medications for CM is their potential for causing medication overuse headache (MOH). One form of MOH is medication overuse headache attributed to combination of acute medications. This is MOH caused by the intake of any combination of ergotamine, triptans, analgesics and/or opioids. CM makes it very difficult to restrict the use of acute medications in order to avoid MOH. There may be days when abortive and rescue medications cannot be used without serious risk of complicating the situation with MOH. Some doctors recommend limiting use of abortive and rescue medications to two or three days a week for this reason. In some cases, other medications to relieve symptoms such as nausea and anxiety may be used so that at least some symptomatic relieve is achieved.
Chronic Migraine and doctor selection
Because chronic Migraine is more difficult to treat and manage than episodic Migraine, it can be especially important to work with a doctor who understands the disease as well as possible and has the experience and continuing medical education needed to provide as much assistance as possible. This is a time when it’s important to remember that neurologists aren’t necessarily Migraine specialists, and Migraine specialists aren’t necessarily neurologists. For more information on selecting and working with doctors, see Migraine Management Essential 1: Diagnosis and Doctors and Is It Time for a New Migraine Doctor?
Effective management and treatment of chronic Migraine depends not only on medications, but also on education, trigger identification and management, and treating comorbid conditions. Preventive medications should be investigated to reduce the frequency and severity of Migraines, reduce the need for acute medications, and improve quality of life. The frequency of CM may mean that there are days when pain cannot be treated without risking developing medication overuse headache.