For the 37 million-plus Americans who suffer from migraines, treatment may start to look different.
The American Academy of Neurology recently revised its migraine prevention and treatment recommendations for the first time in almost 15 years, offering fresh guidance for doctors and patients looking for solutions to the painful and often debilitating neurological condition.
One of the biggest changes: Broadening who qualifies for treatment and updating which treatments are suggested first. Previously, to be considered for preventive care, a patient had to have eight or more migraines a month. That number has been cut in half to just four, according to the new guidelines.
Additionally, a class of drugs called calcitonin gene-related peptide (CGRP) inhibitors, a newer treatment for migraines, are now considered first-line defense medications alongside the more traditional ones already in use.
With new recommendations in place, how you talk to your doctor and what treatments are offered to you may change. This guide covers the biggest takeaways, treatment options and what to expect if you’re considering or are in treatment for migraines or severe headaches.
When to Ask About Preventive Treatment
You may want to start a conversation with your doctor about migraine prevention treatments if:
- You have four or more moderate to severe headache days each month
- You miss work, family activities or social events due to migraines
- As-needed medications meant for temporary relief aren’t enough to manage pain
Choosing Your Treatment Goals
The right treatment for you isn’t based solely on symptoms. Considerations like cost, side effects and frequency can dictate what works for each person’s situation. Think about your primary goals or concerns to discuss with your doctor.
Goal: The most effective options for preventing migraine
Ask about drugs with the strongest evidence of reducing migraine frequency, including Atogepant, Eptinezumab, Erenumab, Fremanezumab, Galcanezumab, Topiramate, Propranolol, Valproate and Botox for chronic migraine.
Goal: Fewer side effects
Ask about drugs that had the fewest side effects and were best tolerated in clinical trials, including Atogepant, Eptinezumab, Erenumab, Fremanezumab, Galcanezumab and Botox for chronic migraine.
Goal: Lower cost
Insurance companies tend to prefer generic medications, which are generally more affordable for people with and without insurance. Ask whether a generic medication could work for you, including Propranolol, Topiramate or Amitriptyline.
Pills, Injections and Infusions
The good news for migraine sufferers is that there are options. If you have a phobia of needles or struggle to remember a daily pill, there are other treatment types.
Daily pills: Patients who prefer to avoid injections and don’t mind staying on top of a daily regimen can discuss Atogepant, Topiramate, Propranolol and Amitriptyline with a doctor. Common side effects include fatigue, dizziness and gastrointestinal symptoms such as diarrhea, constipation or stomach upset.
Monthly injections: People who prefer less frequent treatments can discuss Erenumab, Fremanezumab and Galcanezumab. These drugs are a class of CGRP antagonists, which block the effects of a protein in sensory nerves connected to the head and neck that can cause migraines, according to the Cleveland Clinic. Some CGRP drugs also come in pill form, such as Atogepant. Side effects may include injection-site pain, redness or swelling, allergic reactions and possible high blood pressure.
Quarterly infusions: Eptinezumab can be given intravenously every 12 weeks. It is associated with mild side effects such as a stuffy nose, scratchy throat and allergic reactions.
Botox, generally reserved for chronic migraine sufferers, is also administered on a 12-week schedule. Injections into specific muscles in the head, neck and shoulders can block pain signals from nerves that trigger migraines, according to the Cleveland Clinic.
Other Health Considerations
Other conditions, such as high blood pressure, fibromyalgia, obesity and headaches prompted by medication overuse, are common comorbidities for which there are preferred treatments.
For example, Enalapril, Nifedipine or Telmisartan can help manage blood pressure, and Amitriptyline may improve both migraine and fibromyalgia symptoms.
Pregnancy is also a significant factor in choosing treatment. Some people who are or could become pregnant may opt for a nonmedication approach, such as exercise, trigger management, behavioral therapy and acupuncture. If medication is necessary, Nifedipine, propranolol, metoprolol or Botox may be preferred options.
What to Expect
Although treatments can take a while to begin working, continue the course as prescribed until you can speak with your doctor.
- Medications: It generally takes 8 to 12 weeks at a therapeutic dose to determine whether a medication is successful.
- Botox: It takes about 24 weeks, or about two rounds of treatment, to determine whether it is effective.
Your doctor may ask you to keep a headache diary to measure your progress, track migraine days, rate severity, note missed activities and manage as-needed medications. Doctors may also use in-office assessments and tests to determine whether treatment is working.
Questions to discuss with your doctor include:
- Which preventive treatment best matches my goals?
- What side effects should I expect?
- How long should I try it before deciding whether it works?
- Could one medication affect both my migraine and another health condition?
- Will my insurance cover this treatment?
- What should I do if I plan to become pregnant?
- How will we measure success?
This article is for general information and is not a substitute for medical advice. Talk with a qualified health care professional about your symptoms and treatment options.
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