Do's And Don't's Of Migraine Management. 2024
Migraine is a complicated medical problem, which is thought to be genetic in origin and familial linked. If it is not handled properly with medication and way of living, it can be a terrible, disabling, chronic neurologic problem.
This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, migraine textbook author, podcaster, YouTube video producer, and blogger.
Read my Mini Book on Migraine Here.
Persons with Migraine are born with a special, sensitive brain that reacts to many situations in life that do not affect persons without Migraine.
The Migraine brain reacts to sleep, bright light, heat or warming up, stress or lack of stress, loud sounds, certain odors, red wine, certain foods, or the lack of food from missed meals or fasting.
Additional questions.
1.Why don’t Migraine patients treat with prescription drugs?
Some fortunate Migraineurs can get adequate treatment from just 2 Aspirin and a nap, but they are the lucky ones who are usually rare and “most” Migraine affected persons do better with doctor prescribed drugs and following their doctor’s advice for how to live with Migraine.
Other fortunate Migraine patients can get by with over-the-counter drugs like Excedrin which is Aspirin and caffeine, Tylenol, or one of the NSAIDS, (non-steroidal anti-inflammatory drugs) like ibuprofen, or naproxen. The problem here though is the use of any triptan, NSAID, Tylenol, or Excedrin more than 2 days a week which could start the development of chronic Migraine due to Medication Overuse Headache.
According to the International Classification of Headache Disorders v 3, Chronic Migraine is defined as 15 or more headache days a month, 8 of which have Migraine features such as being moderate or severe, one sided, throbbing, limiting activity, and associated with nausea and vomiting and sensitivity to light and noise.
Episodic Migraine is less than 15 headache days a week.
However, there is a reluctance of Migraine patients to try or to stay on long term the medications that would help them. First drug tried does not always work for Migraine patients; many times, they just have to hang on and try other drugs till they find one that works.
Since 25% of women and 6% of men have Migraine, looking at the other side of that data would report that 75% of women and 94% of men do not have Migraine and do not have to worry about living the Migraine lifestyle or treating with effective medication.
Many Migraine patients are reluctant to use research validated therapy. A survey in 2020 by Health Union of 4,700 Migraine patients found that 1 in 4 (26%) use a preventive Calcitonin Gene-Related Protein (CGRP) medication, (Aimovig, Ajovy, Emgality, Vyepti) down in patient use from 29% in a 2019 survey.
The Migraine timing cycle: There are 4 steps in the migraine timing cycle.
To understand how the new CGRP drugs work it is helpful to understand the Migraine Timing Cycle.
The first step of the Migraine timing cycle is trigeminal nerve inflammation by the brainstem.
The second step occurs at 20-40 minutes when the ganglion of the nerve and artery in the brain start to release the 3 Neuropeptides: Neurokinin A, Substance P, and CGRP.
The third step occurs about 2 hours after the start of the migraine, which is meningeal artery vasodilatation.
Step 4 is chemical inflammation of the Thalamus, called the brain pain center.
The Migraine Timing Cycle
The CGRP antibodies work by blocking the release of CGRP, one of the central neurochemicals involved with an attack of migraine. A recent article posits that Botox injections also may block the release of CGRP as well as block the transmission of C and A sensory fibers.
In the Health Union survey 11% of patients were using Ubrelvy or Nurtec, acute therapy CGRP drug to treat Migraine.
Although the pharmaceutical creators of the new GCRP drugs, such as Eli Lilly, Teva, Amgen, and other drug companies have aggressively marketed CGRP medications and even given the drugs away for free to get people to try them, sales growth has been slow. Only Aimovig and Emgality are used by at least 10 percent of migraine patients.
Many Migraine patients if they are going to take anything, still use the older, cheaper preventive medications for Migraine, such as Amitriptyline, Propranolol, Depakote, Topiramate, or Botox. Amitriptyline and Topiramate were most used according to the survey.
Preventive Medication
Or else they use one of the seven triptans, as acute therapy, which are cheap, generic drugs. Two of them, sc sumatriptan 6 mg and 5 mg zolmitriptan work faster, in 10 minutes and are highly effective giving a headache free experience for 70-80% of Migraines patients in 2 hours.
6 mg subcutaneous sumatriptan for acute Migraine therapy.
Five of the oral triptans have onset at 30 minutes, while frovatriptan and naratriptan start working in 1-2 hours. Speed of treating at onset of the aura or the headache part of a Migraine is important in successful therapy.
The Health Union survey reported that most Migraine patients knew about CGRP inhibitors. (43%) had tried a preventive CGRP but most stopped after taking one of them for a short while.
CGRP antibodies
In the office Migraine patients need a lot of discussion, explanation, and long term follow up to successfully educate and treat their Migraine problem. I know of headache practices where the main neurologist only sees the new headache patient for the first visit and another visit 12 months later as they farm the patient out to a physician assistant or nurse practitioner for the rest of the return visits.
The 4 different preventive CGRP drugs, 7 triptans, DHE by nasal spray and intramuscular administration, and Timolol eye drops gives Migraineurs many choices for acute treatment.
Also, 2020 brought out 3 acute treatment drugs for migraine--lasmiditan (Reyvow; Eli Lilly), rimegepant (Nurtec ODT; Biohaven), and ubrogepant (Ubrelvy; Allergan). These are the first-of-a-kind medications in a new class of CGRP acute migraine treatment which are name brand only, so they are more expensive than the generic triptan drugs. They do not work as well as triptans for effective acute therapy but can be used in patients with cardiovascular restrictions, which is not recommended for triptan therapy.
New 2020 CGRP acute therapy drug
Preventive type CGRP drugs are used by 58% of patients according to the Health Union report and these patients had less head pain and half of them reported they did not react to loud noises or bright lights as dramatically.
Migraineurs who had had heard of preventive CGRP medications but had not tried them cited several reasons: 44% said their doctor had not recommended it, 27% were concerned about side effects, 21% were concerned about long-term safety, 19% said they could not afford them, and 14% said their insurance would not cover CGRP preventive drug treatment.
CGRP preventive drug
Drug makers of CGRP preventive drugs often make Migraine patients who want to use them fail, first for one or sometimes 2 of the older preventive drugs like amitriptyline or propranolol before providing a CGRP drug.
Also, CGRP medications are not cheap. Eight doses of Nurtec, an acute therapy CGRP treatment costs over $1000 without insurance. Nearly half the patients surveyed were still using triptans or over-the-counter pain medication for migraine relief.
2.Why do successful persons with Migraine follow their Neurologists’ lifestyle advice?
The main reason here is that they have found that the Migraine lifestyle works for them.
Migraine is a genetic neurological condition that has a strong familial link. 12% of the world’s population has migraine and women have three times more migraine than men do. Migraine is the most frequent medical condition for women, and it comes with the menstrual cycle in over half of women.
99% of all headaches are either Tension-type headache or Migraine. 70% of headaches are Tension type headache and 30% are Migraine. Less than 1% of headaches are something else. Migraine without aura comprises 70% of Migraine patients and Migraine with aura 30%
Tension Type Headache
Migraine is the seventh most disabling condition among all diseases and the leading cause of disability among all neurological disorders. Persons with Migraine need to learn how to treat it, yet studies show that 56% of persons have Migraine and have never been given a medical diagnosis by a doctor.
Could Migraine be improved by paying close attention to lifestyle issues? This is a question with a certain answer.
Lifestyle issues for Migraine prevention are important and should be performed by all persons with Migraine. These lifestyle suggestions do not just help Migraine, they also improve general health and longevity.
The treatment of Migraine is: Doing the Lifestyle, providing acute therapy medication at onset of a Migraine attack, and preventive medication for Migraine patients with frequent attacks.
These ideas are basic, dogmatic, and like, they have got to be done.
Caffeine is a double-edged sword.
Images of the usual, slowly caffeine addicted patient.
Most persons like to drink caffeine and although it is an addictive drug according to the Diagnostic and Statistical Manual of Mental Disorders V, drinking caffeine can be a very pleasant experience for most people.
The problem is that caffeine is a vasoconstrictor and can aggravate Migraine or give medication overuse headache if too much is used. This issue is especially important to persons with Migraine.
The American Headache Society has stated that caffeine is the number one drug in America causing an increase in the intensity and frequency of migraine. Caffeine use is confusing because many persons know that caffeine may be used to treat headache, but they need to learn that if taken frequently, more than 2 days a week, it can cause medication overuse headache, previously called rebound headache.
As a neurologist and headache doctor I know that many people with Migraine do drink some caffeine and they get by with it and probably do ok, but it is the slow, sneaky addictive quality of the drug that bothers me as a doctor, and I think bothers many Migraine patients.
Overall, I advise Migraine patients to not drink caffeine and my heart sinks when I greet a new headache patient and they sit down, placing their Starbucks 16 oz grande coffee next to them on the table, because I know it contains an exceedingly high dose of 550 mg of caffeine and during the patient’s history will be an important mistake they are making in their lives.
Out of Caffeine ???
Diet issues.
Avoid fasting or missing a meal.
A small breakfast will suffice, but usually for mostly young women, who fill the offices of neurologic headache doctors all over the world, the advice to eat breakfast will be met by a vacant look and denial many times.
Did you know that the word “breakfast: means “to break the fasting of sleep?” If you do not eat and without your knowing it, your pituitary gland will sense your low blood sugar and send out a hormonal signal that will cause vasodilatation of your cerebral arteries and start your “hungry headache” migraine.
Three meals a day is advised by all medically accepted weight loss programs (Jenny Craig/Weightwatchers), but my experience is that most mothers will feed their children three meals a day but not themselves.
Exercise.
The American Heart Association has recommendations for Adults and here is straight copy and paste note from the AHA website.
Recommendations for Adults
Get at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity, or a combination of both, preferably spread throughout the week.
Add moderate- to high-intensity muscle-strengthening activity (such as resistance or weights) on at least 2 days per week.
Spend less time sitting. Even light-intensity activity can offset some of the risks of being sedentary.
Gain even more benefits by being active at least 300 minutes (5 hours) per week.
Increase amount and intensity gradually over time.
The above are recommendations for general health, but did you know that one may improve migraine, anxiety/panic disorder, depression, tension headache, and sleep problems with aerobic exercise?
There are hundreds of scientific articles over the past 20 years proving that exercise works for headache therapy. Aerobic exercise is: dance aerobics, jogging, cycling, swimming, rowing, cross-country skiing, and stair-stepping.
It is not walking, lifting weights alone, stretching, or playing most games, like tennis or racquetball. If you are already exercising and still have bad headaches, consider increasing the aerobic part of your exercise program.
Exercise is something you can do for yourself to take control of your headaches. It takes determination, time, and effort.
Here we go 2,3,4. Work it out 2,3,4.
Overweight can increase the frequency of Migraine attacks.
Some migraine patients get a “work-out headache” if they get hot. If this happens to you then try to work out so you do not get so hot. Exercise in front of a fan or in air conditioning.
Take ibuprofen, Excedrin, or a half of a Triptan drug before you work out, remembering to limit all painkillers and triptans to no more than 2 days per week.
If you still get a work-out headache, then try swimming.
Adequate Sleep.
Migraine persons often do not sleep well. 50% of Migraine patients are depressed or 40% have GAD (generalized anxiety disorder) which both have insomnia as one of the cardinal symptoms.
Regulate your sleep. Set your sleep/wake cycle to rise and go to sleep at the same time every day-even through the weekend. Adults should sleep between 7 to 8 hours every night.
Wake up early on Saturday and Sunday mornings.
Avoid oversleeping Saturday morning or falling asleep for that seductive two-hour nap on Sunday afternoon. Set an alarm for 15-20 minutes for a short, energy restoring nap. If you never learned how to take a short nap, then learn. It can be done.
There are stages of sleep. Most persons with Migraine only get to a light stage of sleep at night, not deep sleep. Too much sleep or not enough sleep can set off a Migraine.
Unwind at the end of the day. Listen to soothing music, take a warm bath, read a favorite book. Quit reading all those emails that always just keep trickling in. Avoid news addiction, it will only make you nervous and intense.
Hard exercise, big meals, caffeine, nicotine, and alcohol can interfere with sleep.
Minimize distractions. Save your bedroom for sleep and sex. Do not watch television or take work materials to bed. Close your bedroom door. Use a fan to muffle distracting noises.
Be sure that none of your medications can interfere with sleep. Look up drug side effects on the internet.
Dealing with Stress
Many patients I talk with deny having any stress. Talking with them is like “It’s somebody else’s problem, not mine.” They either don’t understand what stress is or to discuss it with a “regular, non- psychiatric doctor.
These are the stressful events in life:
Change of environment-leaving home to go to school or start a new job.
Death, accident, or major illness of a parent, grandparent, sibling, close friend, spouse, or sweetheart.
Birth of a new child.
Loss of a job; starting a new job.
Financial stress, mortgages due, old bills, unexpected financial responsibilities.
We all go through these types of things. They are the ebb and flow of our lives.
Therefore, learn to talk over your daily life problems with your friends, family, preacher, priest, or rabbi.
Develop a support system to sustain you in life, built up of key people that are there for you when you need them.
Plan time to relax and spend on hobbies or interests. Normal people have hobbies which is something you do for fun and relaxation, that is creative and not goal or money-making oriented. Children and family are not hobbies. Please look up the word “hobby” in the dictionary if you think this.
Turn off that cell phone, computer, or iPad and get a life. Plan three day weekends several times a year rather than one two-week holiday in August. Leave that depressing, stressful job, or get counseling and try to change a personal relationship that is causing problems.
Try controlled breathing, family, or personal counseling, or learn CBT—cognitive behavioral counselling.
See my www.doctormigraine.com articles on depression, anxiety, sleep, and CBT.
Avoid Overtreatment with Medication.
Do not take too much caffeine, over the counter drugs, triptans, or painkillers for headache. In general, all migraine patients should limit all such drugs to no more than 2 days per week.
The migraine process generates neurochemicals which are released in the brain and that inflame the thalamus, trigeminal nerve, and cerebral arteries. These neurochemicals stay in the body 3 days and once they inflame the brain they are repeatedly released every time other pain killers, caffeine, Advil, Tylenol are consumed, starting a process of continuous headache.
I once saw a man who told me he had been taking 10 Excedrin migraine pills for over fifty years (10 X 65= 650 mg/day) and he had a headache all that time until I convinced him to stop Excedrin. Then his headaches cleared up.
There is no data that opioid narcotics help migraine headache, they just cause problems and should not be used for “rescue treatment.” The U.S. is now going through a change in the use of opioid narcotics and barbiturate drugs since they cause people to die in their sleep, are addictive, and cause medication overuse headache.
There is never any place in neurologic treatment of Migraine to use Opioid drugs like hydrocodone or Tramadol, or barbiturate drugs like butalbital, all of which are Narcotics, possibly addictive, but notorious for causing Medication Overuse Headache.
Narcotics should be reserved only for persons who are in severe pain and near the end of life, for acute trauma, or surgery, and only for a short time and then stopped. Death from opioid narcotics is a top problem now in America and a common problem causing withdrawal of physicians’ medical licenses.
Butalbital found in Fiorinal, Fioricett has been banned in every country in the world except Canada and the U.S. because it causes medication overuse headache. The word “narcotic” comes from the Greek word that means “sleep.”
In Texas, the number one reason for the State Medical Board to restrict physicians medical license concerns their use of opioid medications and more licenses are restricted or revoked regarding this issue than any other.
This is what I take every day, doctor.
Avoid Food Triggers.
People with Migraine may have their own individual foods that seem to set off their headaches and the subject of food triggers is a controversial, still poorly researched subject.
Common food triggers are: alcohol, chocolate, aged cheeses, MSG, and red wine. If you know certain foods are a problem for you, do not eat them.
Alcohol induced headache
Eat regular, balanced meals. Basing your diet primarily on fruits, vegetables, whole grains, lean protein, and healthy fats (and limiting foods that trigger an attack) is a good way to prevent Migraines and/or headaches. Also, do not skip meals. Skipping meals makes you hungry, which can trigger a migraine.
Avoid all your known Migraine Triggers.
Migraine triggers may be:
Stress 79.7%
Hormones (in women) 65.1%
Not eating 57.3%
Weather 53.2%
Sleep disturbance 49.8%
Perfume or odor 43.7%
Neck pain 38.4%
Light (s) glare 38.1%
Alcohol 37.8%
Smoke 35.7%
Sleeping late 32.0%
Heat 30.3%
Food 26.9%
Exercise 22.1%
Sexual activity 5.2%
Reference. Kelman writing in Cephalalgia in 2007 on “The triggers or precipitants of the acute migraine attack.”
Check Barometric Pressure changes aggravating Migraine.
There are scientific articles verifying Migraine attacks with changes in barometric pressure. I think this has been established the reason for the attacks and how pressure affects the brain is not understood.
Modern cell phones or computers can report current barometric pressure changes for where you live. If you get attacks with barometric pressure changes, then keep a pressure diary and watch out for a Migraine that may occur then. Migraineurs may pretreat with a triptan for some attacks.
What to do when a Migraine does start.
Treat early with a Triptan when a Migraine starts. Find a cool, dark, quiet space. Get off TV or your cell phone. Rest your eyes.
Relax. Deep breathing from your diaphragm can help you relax. Focus on inhaling and exhaling slowly.
Think positively. Learn how to deal with a Migraine interrupting your day. Learn CBT skills. Think: “It’s not the end of the world.”
Keep a migraine diary.
There are several free cell phone apps for migraine. I have a blog post on the subject at www.doctormigraine.com.
Patients can plot life issues on their Migraine apps—menstruation, weather change, stress, missed meals, occurrence at night or a “wake up headache.”
Free Migraine App
Migraineurs should carefully study any trigger that seems important and recurrent. Living with migraines is a daily challenge but making healthy lifestyle choices can help. Ask your friends and loved ones for support and advice. Pray to God for help with your life and your health.
Check out my Big Book on Migraine Here.
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All the best.
Britt Talley Daniel MD