Treatment Options for Episodic vs. Chronic Migraine

Reviewed by: HU Medical Review Board | Last reviewed: April 2024 | Last updated: April 2024

If you have migraine disease, you are far from alone. More than 1 in 6 adults in the United States deal with migraine. In fact, it is one of the most common acute medical issues.1-5

There are 2 general types of migraine:1-5

  • Episodic migraine – Migraines occur 0 to 14 days per month
  • Chronic migraine – Migraines occur 15 or more days per month

This or That

Which type of migraine do you live with?

Some migraine treatments are acute or abortive, meaning that you use them at the time of an attack to resolve symptoms. Preventative treatments can be used regularly in between migraine attacks to help lower the frequency or severity of future migraine attacks.5

Trying out a combination of acute and preventative therapies under the advisement of your doctor or neurologist can help reduce migraine frequency and symptoms.5

Acute treatments for episodic and chronic migraine

Acute treatments for migraine usually include a combination of:1,3,6,7

  • Nonsteroidal anti-inflammatory drugs (NSAIDs), like aspirin, Motrin® and Advil® (ibuprofen), and Aleve® (naproxen)
  • Triptans, like Imitrex® (sumatriptan)
  • Tylenol® (acetaminophen)
  • Calcitonin gene-related peptide (CGRP) antagonists
  • Reyvow® (lasmiditan)
  • DHE 45® and Migranal® (dihydroergotamine)

NSAIDs and triptans are the first-line choices for acute migraine treatment, especially for episodic migraine. This is because there is less risk of medicine overuse.1,3

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Many people living with chronic migraine worry about taking acute treatments for fear of medicine overuse. In the early stages, it is best to work with your doctor to figure out a pattern of good days and bad days and identify any triggers. Then together you can initiate an acute treatment plan to treat your migraines. In general, attacks should be treated early and drug doses should be slowly increased to the lowest effective dose.3

Noninvasive vagus nerve stimulation can help relieve migraine pain as well. Opioids do not improve migraine pain and are not effective as a migraine treatment.1

Preventative treatments for episodic migraine

Preventative treatment for episodic migraine can include several different strategies, including drug treatment and identifying triggers. Drugs that have been found effective for episodic migraine prevention include:2

Amitriptyline, venlafaxine, atenolol, and nadolol are all likely effective as well. But they are more commonly used if first-line therapies do not work.2

CGRPs for episodic migraine

A relatively new class of preventative migraine medications called calcitonin gene-related peptide (CGRP)-inhibitors or antagonists. These medicines consist of monoclonal antibodies or small molecules that inhibit CGRP. Blocking CGRP decreases inflammation and nerve pain associated with migraine.6,7

The antibody-based CGRP therapies are given by injection or infusion, often once a month or every 3 months, and the small molecules of CGRPs are taken by mouth.6,7

Anti-CGRP monoclonal antibodies – taken as injections – include:6,7

Small molecule CGRP inhibitors – taken orally – include:6,7

Preventative treatments for chronic migraine

The same drugs that are effective for preventing episodic migraine may also help prevent chronic migraine.
Botox® (onabotulinumtoxin A) is the only other drug approved as a preventative treatment for chronic migraine. Botox is injected into the muscles of the neck and face by a trained doctor.8

Botox works by binding to receptors on nerves and muscle fibers. This blocks the release of several brain chemicals that block muscle activity. Doctors believe Botox may reduce headache pain and stiffness by blocking nerves that send pain messages to the brain and relaxes muscles so they are less sensitive to pain.8

CGRPs for chronic migraine

Data suggests that CGRP inhibitors may have the best efficacy and safety profile for episodic and chronic migraines. As a result, CGRP inhibitors are being used more commonly for preventative (and abortive) therapy in chronic and episodic migraines.3,4,6

CGRP injections approved as preventative treatments for chronic migraine include:6,7

  • Aimovig® (erenumab)
  • Ajovy® (fremanezumab)
  • Emgality® (galcanezumab)
  • Vyepti® (eptinezumab)

Qulipta® (atogepant) is the only oral CGRP drug approved as a preventative treatment for chronic migraine.6,7

What non-prescription options can you turn to?

Identifying and avoiding migraine triggers can also help prevent episodic or chronic migraine attacks. Managing migraine triggers effectively can maximize the effects of any other migraine treatments you may take.3

Common migraine triggers include:2

  • Missing meals
  • Stress
  • Weather changes
  • Menstruation
  • Certain foods
  • Certain smells

Many people find it helpful to keep a “headache diary” with information about their sleep regimen, hydration, meals, and stress. Tracking these different factors, and figuring out when your migraine attacks occur as a result, can help you to recognize potentially helpful lifestyle solutions to reducing the attacks.3

Before beginning treatment for migraine, tell your doctor about all your health conditions and any other drugs, vitamins, or supplements you take. This includes over-the-counter drugs.