Treatment Options for Episodic vs. Chronic Migraine

If you have migraine disease, you are far from alone. More than 1 in 7 adults in the United States experiences 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 – Migraine occurs 0 to 14 days per month
• Chronic migraine – Migraine occurs 15 or more days per month

Some migraine treatments are acute or abortive, meaning that you use them at the time of an attack to resolve symptoms. Preventive 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 headache provider 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:^1,3,6-9

• Nonsteroidal anti-inflammatory drugs (NSAIDs), like aspirin, Motrin^® and Advil^® (ibuprofen), and Aleve^® (naproxen)
• Triptans, like Imitrex^® (sumatriptan) and Symbravo^® (meloxicam and rizatriptan)
• Tylenol^® (acetaminophen)
• Calcitonin gene-related peptide (CGRP) antagonists
  • Zavzpret™ (zavegepant)
  • Nurtec^® (rimegepant)
  • Qulipta^® (atogepant)
• Reyvow^® (lasmiditan)
• DHE 45^®, Migranal^®, Trudhesa®, Atzumi® (dihydroergotamine)
• Brekiya® injection (dihydroergotamine mesylate) – this is the first and only DHE autoinjector for the acute treatment of migraine with or without aura and the acute treatment of cluster headaches in adults.

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; however, there still is a risk if taking these drugs more frequently than 2 to 3 times per week.^1,3

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 healthcare provider 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 migraine attacks. In general, attacks should be treated early, and drug doses should be effective and well-tolerated with minimal side effects.³

Noninvasive vagus nerve stimulation can help relieve migraine pain as well. Opioids and butalbital-containing medicines are not effective as a migraine treatment and contribute to overuse and withdrawal symptoms.¹

Preventive 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

• Lopressor® and Toprol XL^® (metoprolol)
• Inderal^® LA (propranolol)
• Eysano^® and Timoptol^® (timolol)
• Depakote^® (divalproex)
• Topomax^® and Topiragen^® (topiramate)

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

• Aimovig^® (erenumab)
• Ajovy^® (fremanezumab)
• Vyepti^® (eptinezumab) – this is an infusion only
• Emgality^® (galcanezumab)

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

• Qulipta^® (atogepant)
• Nurtec^® (rimegepant)

Preventive treatments for chronic migraine

Many of the same drugs that are effective for preventing episodic migraine may also help prevent chronic migraine. Data suggest that CGRP inhibitors may have the best efficacy and safety profile for episodic and chronic migraine. 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

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 healthcare provider.⁸

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

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.