“We’ll see two people who have the same diagnosis of migraine, and one will do really well with one treatment, but the other won’t respond to that treatment at all,” says Robert Cowan, MD, FAAN, chief of the division of headache medicine at Stanford University. According to the American Migraine Foundation, more than 37 million Americans live with migraine, and trial and error is often part of the treatment process. Fortunately, there are many options available. Consider these facts as you work with your doctor to find the right migraine treatment plan for yourself.
1. Pain relievers can help ease migraine pain, but taking them too often might trigger medication-overuse headaches.
When your head hurts, pain relievers can seem like a blessing, but if you take them too often, they can become more of a curse. People with migraines who take too much headache medication may experience a secondary type of headache called medication overuse or rebound. While the cause isn’t fully understood, a study published in the July/August 2017 issue of the journal Pain Reports suggested that the brain may develop a dependence on the medication or that genetic factors may play a role. Some people overuse medication because they want relief for frequent headaches and don’t know what else to do, says Dr. Cowan. In other cases, people are prescribed the wrong medicine or are not given proper guidance on how to take it safely. “A general rule of thumb is that acute medications … should not be taken more than 10 days a month,” says Cowan, but preventive headache medications should be taken as prescribed. Keep in mind that there are exceptions to this rule; some medications may be safe to take five days a month, while others may be safely taken a few days a week. Any time you are prescribed something new, ask your doctor how often you can take it. If your doctor determines that you have medication-overuse headache, they will likely prescribe you a preventive medication to help ward off headaches, recommend that you start behavioral therapies to reduce headache susceptibility, and support you as you reduce your use of the offending medication.
2. Preventive medications can ward off headaches, but they can’t cure the underlying disease.
Preventive treatments might reduce the frequency of your headaches, but they won’t banish them entirely. Migraines are believed to be caused partly by genetic factors, and you can’t change those, says Cowan. So it’s important to keep your expectations realistic. For example, if you have a migraine 28 days a month, an effective treatment might reduce your headaches to eight days per month, he explains. But the treatment might not eliminate migraines altogether. To maximize the benefits of preventive medications, practice good sleep habits, exercise daily, and schedule regular meals. “All of these things make you more resistant to a migraine attack, so a given trigger is less likely to bring on a migraine,” says Cowan. It’s also important to avoid triggers as much as you can.
3. You may want to see a specialist.
Start with your primary care doctor, the quarterback of your healthcare team, says Cowan. They can manage many headaches, but if the pain persists, you might need a specialist. “If you’re not getting better after a couple months, it’s time to escalate … to a general neurologist; if that doesn’t work after a couple more months, [then it’s] time to move on to a headache specialist,” says Cowan. Specialists are more familiar with migraine treatments and diagnosis, and the first challenge in treating migraines is receiving the right diagnosis, he says. For example, many people who think they have sinus headaches — and are treated accordingly — in fact have migraines, he says. And some people who are treated for migraine to no avail may have another underlying condition, such as cerebrospinal fluid leak, causing their pain.
4. Some treatment plans fail after time.
The right treatment can bring you years of relief, but sometimes that relief starts to fade. “Generally, we find that a treatment that works will continue to work pretty well unless there’s a change in behavior or environment,” says Cowan. Stressful life events, such as divorce, or hormonal fluctuations caused by the onset of menopause could ramp up your migraines. Or headaches may start as a side effect to a new medication for another problem, such as high cholesterol. If you feel you are having more migraines than usual or they appear to be changing, talk to your doctor, who will do a bit of detective work to determine what is bringing on the new pain and how to adjust your treatments, says Cowan.
5. Not everyone needs preventive meds.
Some people — especially those with frequent or severe headaches — will need a three-pronged treatment strategy. Acute medicines are used when a headache first begins. Rescue medication is taken if the acute treatment doesn’t work. Then there are preventive medications, which you take every day to reduce your likelihood of getting a migraine. If you have infrequent headaches that respond well to acute treatments, then a combination of acute treatments and lifestyle changes might be enough, and a preventive treatment might not be recommended. Your doctor will help you develop a treatment plan that works with your headaches and any other health challenges you face. “How we select which medication is the acute treatment, the rescue treatment, and the preventive treatment has a lot to do with how the patient presents and the side effect profile,” says Cowan. For example, if you have depression and anxiety, your doctor might recommend a preventive that’s also an antidepressant.
6. Complementary therapies might also help prevent migraines.
Not all headache relief comes from a prescription. Mindfulness meditation might help reduce headache frequency and intensity, in part because it improves self-efficacy and quality of life, according to a study published in 2018 in the Chinese Medical Journal. If you can, Cowan recommends taking a class in mindfulness-based stress reduction (MBSR), which is offered by many hospitals and health networks. A meditation app can also help. Another evidence-based option is cognitive behavioral therapy (CBT), which is administered by a mental health professional and can help you challenge unhelpful thoughts and modify your behaviors. Acupuncture relieves pain for some headache sufferers, but the results can be mixed, probably because of variability among practitioners, says Cowan. Some people who suffer from migraines find that dietary supplements such as riboflavin, magnesium, and coenzyme Q10 can help with prevention, says Cowan. Talk to your primary care doctor before taking any supplements. Another route that works for some people are medical devices that stimulate certain nerves or parts of the brain in order to relieve pain. Ask your doctor if this option is right for you. Regardless of which therapy you try, it’s always important to log enough sleep, stay hydrated, and exercise regularly.
7. You need to give your treatments time to work.
“When you try something, make sure you give it an adequate trial,” says Cowan. If you start a preventive medicine and have a headache the next day, don’t assume that the medication failed, he says. “Give your treatments enough time — usually two or three headaches for an acute treatment — before you [decide] whether it works,” he says. “For a preventive, it’s usually two or three months once you’re on the right dose.” Above all, don’t give up. “We see patients all the time who’ve had inadequate trials and say nothing has worked,” he says, but medications need time to start working.
