Severe Migraine Treatment 2024
Migraines are found in (12% of the population) and are described as being moderate to severe, disabling (put you to bed), and associated with disagreeable symptoms- (photophobia-fear of light, sonophobia-fear of sound, osmophobia-smells make you sick, nausea-upset stomach, and vomiting-where’s the paper bag?)
Really, as a chronic, genetic, episodic long term neurologic problem, what could be worse? Many persons with Migraine never figure out what to do, they survive the attacks, somehow, but do not have an organized plan.
Considering the usual disabling outcome—WHAT SHOULD YOU DO FOR A SEVERE MIGRAINE?
Read my Mini book on Migraine here.
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.
To treat a severe Migraine several things should be done. This is the list:
Stop what you are doing now and give in to the headache.
Lie down.
Get in the dark.
Get in the quiet.
Hydrate with fluids.
Go to sleep.
Use ice packs.
Turn off your cell.
Take your medication early, preferably a triptan.
Later-see a doctor and get on a preventive medicine if you suffer 3 or 4 Migraines a month.
After the attack—do the Migraine lifestyle and meet the right doctor:
Doctor rest.
Doctor eat good.
Doctor sleep right.
Doctor low stress.
Doctor nature.
and Doctor exercise.
Additional questions:
What is it about lying down with a Migraine?
The International Classification of Headache Disorders v.3, which is the standard reference for Migraine classification worldwide, states that persons while suffering a Migraine find that “activity worsens the headache.”
Many persons with Migraine think, “Not again,” when they first notice the headache coming on as an inkling of pain behind their left eye, perhaps. And they may choose to ignore the initial symptoms and see if they will just go away. Sometimes this is works and the reluctant migraineur finds the headache abates.
But this is a gamble and usually that unprepared person with Migraine finds the whole world comes down on them as they develop a severe, untreated Migraine that upsets their day and sends them home from work mid-morning in a work colleague’s car with their tail between their legs.
For treating a Migraine, it is better to just give in to it, take your medicine, and lie down, rather than take a dangerous risk with a Migraine that may last all day, or for several days. And remember you will feel better with a Migraine if you lie down.
In bed with a Migraine
Why is it better to get in the dark with a Migraine?
Migraine comes with photophobia, a neurologic symptom meaning fear of light. Photophobia during a Migraine is pain caused by retinal exposure to light. The retinal fibers behind the eyeball connect to the fifth cranial nerve, a sensory nerve which carries pain. The trigeminal nerve is activated by the Migraine neurophysiologic process to cause pain during a headache. This is usually pain on one side of the head behind the eye.
Migraineurs want to get into the dark, because it helps their headache pain. They feel better in the dark.
Why is it better to get into a quiet place during a Migraine?
Migraine aggravates the sensory nerves for pain in the face, the fifth cranial or trigeminal nerve, and the sensory nerve for vision, the optic nerve and the retinal fibers behind the eye. Migraine also inflames the eighth cranial nerve which carries hearing so that small sounds the Migraine person experiences sound VERY LOUD AND AGGRAVATING.
They feel better in a quiet place.
How does dehydration provoke Migraine?
It is not clearly understood medically how dehydration aggravates Migraine. But it does. Normally we need 64-80 ounces of fluids and losing 1-2% of fluid body weight from not eating and vomiting can cause dehydration.
Years back while I was looking for an internship, I met with a doctor from a Midwestern medical school who had invented GATORADE. Wow! He probably made a lot of money. That was the beginning of treating dehydration with balanced electrolytes and water, a concept that is dogma now in sports and work outs.
Consider rehydrating with plain water, Gatorade, or a similar sports drink when your Migraine comes on.
Ahhh
Go to sleep.
I know that this is going to sound empty, and I don’t know how it works but many patients have told me that going to sleep will get rid of their Migraine. That is probably hard to do, go to sleep in the middle of severe headache pain and nausea. But some persons are able to do it.
Sleep sort of resets the Migraine brain. But long sleeping like with 4-hour afternoon naps after a severe Migraine may make the headache worse. It’s okay to sleep off a Migraine with a couple hours sleep but then get on your regular daily awaken/go to sleep schedule.
They also say their headache gets better if they vomit and I don’t really understand that either, but I believe it.
How does ice help a Migraine headache?
Well, a backwards way to look at this, I think, is to look at internet sites on Pinterest or Google for headache treatment and you will find an enormous number of treatments offers using ICE. There are ice bags, and ice sacks, and ice hats, and so on. It is pretty obvious that ice is a popular and sought out over the counter treatment for Migraine headache.
I am the father of five kids, and we have always kept an ice cube wrapped inside a blue bunny in our freezer. Always. My wife calls it the “Boo boo Bunny” and she puts it on anything that hurts for the kids, grandchildren now—bumps on the head, falls to the ground on the hip, and so on.
The reason we do this is because ice treatment helps pain, and it helps the affected Migraineur to put an ice pack on their head during a Migraine. Shoot, they even do this in the ER for any kind of traumatic injury.
How does the advice to “Turn off your cell” help?
Most persons realize that cell phones have good and bad issues. They are great for phone calls, or to recall because you don’t have to reenter the numbers. And when they connect to the internet—watch out! Anything is possible.
A guy in a male study group I attend weekly always pulls his cell out to win his arguments. They store a tremendous amount of data. They wake us up in the morning and remind us what to do every day.
But my heart sinks when I see a young married couple sitting at a restaurant and independently reading their cell phones. Cell phones destroy talking and human relationships.
So, as a doctor I want my patient with a severe Migraine to just rest—not surf the net, or text somebody. Also, I want them to REST THEIR EYES by closing them because of the light and photophobia and all that. I often advise them to not watch tv or read with a severe Migraine.
Can’t people just lie down and rest and do nothing for a period of time? I’m the doctor. That’s what I want.
Take your Migraine medicine at headache onset, preferably a triptan.
Only triptans can give 70-80% of migraineurs a headache free experience at 2 hours. No other drug can do this. Over the counters like ibuprofen, naproxen, or Excedrin help some but many persons with Migraine tell me they just don’t take anything available to them because they don’t work They really need to see a doctor and get on medication.
You do have to see a doctor to get a prescription for one of the 7 triptans and that will often be sumatriptan,
List of Acute Therapy Options—to be taken when the Migraine starts. Listing from simple to more complex and effectiveness.
Tip regarding medication therapy. Rebound potential listed below means one may develop medication overuse headache by over treating-over the counters more than 15 days/month or triptans more than 10 days/month.
Over the counter drugs:
Aspirin (5 grains) with caffeine (60 mg) (Excedrin, Vanquish) 2-3 at onset, then repeat every hour X 2. Limit to 2 treatment days a week. Rebound potential.
Tylenol (acetaminophen) or an NSAID (non-steroidal anti-inflammatory drug), such as Aleve (naproxen) or Advil (ibuprofen. The dose is 1-2 at onset and repeating once in 2 hours if no improvement. Limit 2 days a week. Rebound potential.
Cafergot (100mg caffeine and 1 mg ergotamine) The dose is 1-4 at the onset within the first 30 minutes of headache. Use the lowest dose needed to determine what your dose. It is usually 2-3 Cafergots per headache.
Not to be used within 24 hours of taking a triptan. Limit to 2 treatment days a week. Max 12/month. If Cafergot makes you nauseated, pretreat with Reglan 5 mg. Rebound potential.
Cambia (diclofenac potassium for oral solution) This is a non-steroidal anti-inflammatory (NSAID) drug indicated for acute treatment of migraine attacks with or without aura for persons 18 years of age or older. A single 50 mg dose should be given at onset by mixing a single packet contents with 1-2 ounces (30-60 mm) of water. The most common adverse reactions are nausea and dizziness.
Prescription drugs
Migranal Dihydroergotamine (DHE) Nasal spray 4mg/ml. One spray (0.5 mg dihydroergotamine) to each nostril at onset every 15 minutes X2 (this is one dose), Max 4 doses per attack, 6 per day, and 8 per week. The half-life is long 10 hours. No reported Rebound potential. This drug may be used for medication overuse headache.
Dihydroergotamine (DHE) for Intramuscular injection—1 cc at onset of a migraine, Max 3 mg/day, 6 mg/week, may repeat dose every 1 hour. Has to be drawn up from a bottle like insulin and injected in the muscle. May repeat X 1 after 6 hours. No reported Rebound potential. It requires an injection but it can be very effective. The injection is about 6 times more powerful than the nasal spray. Side effects are leg cramp or elevation of blood pressure.-
Triptans treat migraine headaches after they’ve started. Take yours as soon as possible. They work best that way.
Imitrex (sumatriptan) most effective when given via a gun type injector. The medicine comes in a vial with a needle and is loaded into the injector like a bullet. The medicine is then injected subcutaneously by pushing a trigger. This is a very slick, high tech system.
The dose is 1 injection (6mg) at the onset of a migraine, may be repeated at 1 hour for a total dose of 12 mg/24hrs. An oral pill exists also: 25 mg (for kids) or 50, 100 mg (for adults). The usual dose is 50-100 mg at the onset of headache, may repeat at 2 hours (max 200mg/day).
An Imitrex nasal spray is also available as 1-10 mg squirt per nostril per migraine. For Imitrex the highest drug levels are obtained with the shot, medium drug levels with the pills, and low drug levels with the nasal spray.
Some patients find the Imitrex nasal spray tastes bad when it goes down the back of the throat. Imitrex went generic December 2008. Rebound potential. Limit to 2 treatment days/week.
Sumavel DosePro needle free. This is a transdermal, one time use, application supplying 6 mg of sumatriptan subcutaneously by a pressure jet through the skin. Dose is 1 at onset, may repeat in 1 hour. Rebound potential. Limit to 2 treatment days/week.
Treximet (sumatriptan 85 mg, naproxen 500mg). May be more effective than Imitrex alone. Rebound potential. Limit to 2 treatment days/week.
Tip regarding subcutaneous injections—YouTube has instructional videos on how to do this on the internet.
Zomig (Zolmitriptan) should decrease the dose by 50% if taken with Tagamet (Cimetidine). Comes as a 2.5 mg or 5 mg tab to be taken one as needed for migraine, trying the 2.5 mg dose size first and moving up to 5 mg (max 10mg/day). Dose at onset 2.5 or 5 mg, may repeat in 2 hours. Also comes as a dissolvable tablet 2.5, 5 ZMT and as a nasal spray 2.5, 5 mg. Rebound potential. Limit to 2 treatment days/week.
Maxalt (Rizatriptan) comes as a MLT (melt in your mouth) 10 mg wafer and 5, 10 mg tablets. Both are absorbed in the stomach and the MLT, which some patients consider more convenient, is absorbed slower than regular Maxalt. Should reduce the dose by 50% if taken with Inderal (Propranolol). Dose is 1 at onset, may repeat in 2 hours, or take another dose 2 hours later. Maxalt is the only triptan that can be dosed 3 tablets/day. Max 30 mg/day. Rebound potential. Limit to 2 treatment days/week.
Axert (Almotriptan) Comes as a 6.25 and 12.5 mg tablet. In controlled clinical trials, single doses of 6.25 mg and 12.5 mg of Axert tablets were effective for the acute treatment of migraines in adults, with the 12.5-mg dose tending to be more effective. Dose is 1 at onset, may repeat in 2 hours. Rebound potential. Limit to 2 treatment days/week.
Relpax (Eletriptan) Comes as a 20 and 40 mg tablet. The 40 mg tablet seems to work the best. Dose is 1 at onset, may repeat at 2 hours. Contraindicated with Antifungals, Macrolide Antibiotics, and Protease Inhibitors. Rebound potential. Limit to 2 treatment days/week.
Amerge (Naratriptan)—2.5 mg tablet which is the initial dose. May repeat in 2 hours. Onset is 1-2 hours. Amerge is a specialty niche migraine medication for those whose migraine generator in the brain produces a long, slow onset profile. It is promoted for menstrual Migraine.
This drug stays around long enough to outlast this type of migraine. The duration of activity is long—6 hours as opposed to 2-3 hours for most of the other triptans, except Frova. Rebound potential. Limit to 2 treatment days/week.
Frova (frovatriptan) ---Onset 1-2 hours. Good for migraineurs with long duration headache generators. It has a very long duration (26 hour half-life) and lasts four times longer than any other triptan. Thus, it is the drug of choice for menstrual migraine. Taking birth control pills or Inderal may increase blood levels of Frova. Treat with an initial 2.5 mg dose, may repeat in 2 hours. Rebound potential. Limit to 2 treatment days/week.
Sumatriptan
Medical Devices
Cefaly is an electronic device that provides acute and preventive treatment for Migraine. Cefaly attaches by an electrode to the forehead and sends pulses to the upper branch of the trigeminal nerve which regulates migraine pain. Cefaly is a medical device which has very few side effects and can help persons with migraine who don’t want to take or who respond poorly to available migraine medications.
GammaCore is effective for patients who have failed traditional oral or injectable medications such as triptans, caffeine, or NSAIDS. GammaCore treatment for migraine avoids medication side effects and limits the possible development of medication overuse headache. GammaCore has also been approved for Cluster headaches.
New oral pills.
Ditan Reyvow (lasmiditan) is the first of a new treatment , called a Ditan, for the acute treatment of migraine with or without aura.
Gepants Nurtec (Rimegepant) is the first of a new kind of acute drug treatment for migraine. Nurtec (Rimegepant) is given as a fast acting orally disintegrating 75 mg tablet to patients with episodic or chronic migraine.
Nurtec is the only drug that works for both prevention and acute onset of Migraine.
Ubrelvy (Ubrogepant) is a calcitonin gene-related peptide, CGRP, receptor antagonist for the acute treatment of migraine with or without aura in adults.
Triptans work better than any of these new oral pills which are expensive and name brand now. All triptans are generic and cheaper.
Later-see a doctor and get on a preventive medicine if you suffer 3 or 4 Migraines a month.
The number of advising preventive treatment for 3-4 Migraines comes from general consensus among headache doctors. Only half of persons with Migraine have had a diagnosis from a doctor. There are 4 commonly used preventive drugs for Migraine (amitriptyline, topiramate, propranolol, and Depakote) that reduce headaches by 30-40% but most patients don’t stay on these drugs very long.
Using one of the new CGRP drugs results in half of patients getting 50 % reduction in migraine headaches. Another 25 % of patients get 75 % reduction in migraine and another 25 % of patients, the so-called “super responders” get 100 % reduction of migraine headaches. All the drugs work about the same for Migraine prevention.
The CGRP drugs are Aimovig, Ajovy, Emgality, and Vyepti.
These drugs are name brand and expensive and require an office visit or 2 with a doctor to get them but regrettably they currently are used by only 10% of Migraine patients.
Migraine Patients—do the Migraine lifestyle, take a triptan quickly at the onset of a Migraine, and if you are having a lot of Migraines—get on a preventive drug.
Check out my Big Book on Migraine Here.
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All the best.
Britt Talley Daniel MD