What helps migraine headaches?

Mythbusters: Migraine Remedies

Alternative Treatment Methods That May Not Be Worth the Headache

One internet search will provide endless advice about alternative medical approaches, especially when it comes to migraine treatment. From vitamins to homeopathic remedies, exercises and essential oils, everyone swears that their solution works. But with all the clutter on the internet, you have a right to proceed with caution. To help you cut through the noise, we investigated some of the most common alternative migraine remedies to see which ones hold water.

Alternative Migraine Remedies

Magnesium: Found in many greens, nuts seeds and grains, magnesium is known to reduce stress, can help reduce migraine frequency, and has few side effects. Studies suggest magnesium supplementation can be helpful for migraine with aura and menstrual-related migraines. In fact, both the AAN and Canadian guidelines recommend its use for migraine prevention, either as oral magnesium citrate 400-600 mg daily or by eating more magnesium-rich foods. Doctor Says: Effective

Homeopathic Migraine Treatment: The homeopathic theory says that if you take a minuscule amount of an element that causes symptoms like the symptoms that you are experiencing, your body will repair itself. Examples of this could be belladonna and other poisonous herbal substances. Tests have never proven homeopathy to work, and Britain is considering banning homeopathy from its National Health Service. Doctor says: Not effective

Butterbur: Butterbur comes up regularly in migraine circles as an effective migraine treatment method—and studies support that it is effective for prevention in some patients. However, due to a rare but serious risk of liver toxicity, it has been removed from the market from some countries, and many headache experts in the US have stopped recommending its use. Doctor Says: Effective, but proceed with caution and know the risks

Essential Oils: A small bottle of lavender can help you to relax (although not in a medical fashion), and can be very pleasant as well. In a modern pyramid scheme, however, consumers are sold an entire set of essential oils, and assured that they can “treat” a plethora of ailments, even encouraged to use essential oils instead of medicine. While one or two oils might smell nice, there’s no need to purchase an entire set, and they should not be substituted for medicine. Doctor says: Not effective

Acupuncture for Migraine: The National Center for Complementary and Integrative Health reports that studies have proven that acupuncture can be effective in fighting chronic pain, like headaches. Many doctors work with and recommend acupuncturists, especially because it is minimally invasive and can garner results for migraine patients. Doctor Says: Could be effective

Remember, every person responds to treatment differently, so please make sure to consult a doctor before adopting any new migraine remedies.

Please contact us with any questions.

Identifying & Treating Migraine

There’s no cure, but there are treatments that can reduce migraine frequency, severity, and stop a migraine attack before it gets worse.

Here are general categories of treatment and what they are intended to do:

  • Preventive treatments—These are designed to reduce headache frequency and severity. These treatment options can be pharmacologic, such as medications or procedures, and non-pharmacologic, such as treatment devices, lifestyle changes, trigger avoidance, behavioral therapy, or physical therapy. These preventive treatment options work in about 40% of patients and typically reduce migraine frequency by at least 50%.
    • There is only one FDA approved treatment for Chronic Migraine (attacks occur 15 or more times a month, and that is onabotulinumtoxinA (Botox.) For more on Botox, see https://headachejournal.onlinelibrary.wiley.com/ in an article by Emily D. Mauser and Noah L. Rosen, MD in the American Headache Society’s journal Headache.
  • Acute or as needed treatments—these are taken when you are experiencing a migraine attack and are designed to stop it before it gets worse. These include over-the-counter pain relievers, prescription medications, or treatment devices.

For a fuller discussion of treatments, visit these pages on AmericanMigraineFoundation.org:

  • Acute Treatments
  • Behavioral Treatments
  • Treatment Devices
  • Preventive Treatments

What’s Next?

There is hope on the horizon. In recent years, migraine science has made great advances to understand brain chemistry, pain pathways, and migraine genetics, which may lead researchers deeper into the search for cures.

Among those that excite migraine scientists is work with the calcitonin gene related peptide (CGRP), which seems to block transmission of pain and stop migraine attacks before they get started. Several pharmaceutical companies are now involved in the study of drugs based on the actions of CGRP.

For more on CGRP, please read the article by David W. Dodick MD of the Mayo Clinic and Chairman of the American Migraine Foundation’s 36 Million Migraine Campaign. https://americanmigrainefoundation.org/resource-library/promising-new-science/

You may also want to read more about other interesting work in the search for a cure. The American Headache Society’s professional journal is packed with information for those who want to dig deeper. Visit http://www.headachejournal.org/view/0/searchResults.html?q=promising+research to see more.

What’s in the “Pipeline”? Experimental and Recently Approved Migraine Therapies

By
Stephen D. Silberstein, MD
Director, Jefferson Headache Center
Thomas Jefferson Medical Center

Drugs

1. CGRP (calcitonin gene-related peptide) Antagonists

  • Four companies have CGRP-focused monoclonal antibodies in development to treat episodic and chronic migraine (migraine headaches that occur 15 or more days a month and affect 3.2 million Americans). CGRP binds to the CGRP receptor and is involved in migraine pain. CGRP levels increase during a migraine attack and often remain elevated in the blood stream in chronic migraine. Three companies are developing monoclonal antibodies directed against CGRP, and one company (Amgen) is developing a monoclonal antibody directed against the CGRP receptor complex.
    • Alder Biopharmaceuticals is developing ALD403, a monoclonal antibody to CGRP.
    • They have completed a controlled proof of concept study published in Lancet Neurology. Sixty percent of patients had a 50% response (Placebo was 33%), and 16% had a 100% response rate (Placebo was 0%)
    • Amgen is developing AA32, a monoclonal antibody directed against the CGRP receptor complex. They have completed preliminary studies.
    • Eli Lilly is developing LY2951742, a monoclonal antibody to CGRP. They have completed a Phase II randomized, double-blind, placebo controlled study published in Lancet Neurology. Thirty-one percent of patients receiving the drug had a 100% reduction in headache days. Drug was originally developed by Artaeus Pharmaceuticals, which was bought by Lilly.
    • TEVA Pharmaceuticals is developing LBR-101, a monoclonal antibody to CGRP. Has conducted Phase IIB trials. They have completed preliminary studies. TEVA acquired the rights to LBR-101 when it bought Labrys Pharmaceuticals.

2. Lasmiditan (5HT1F agonist)

  • CoLucid Pharmaceuticals is developing Lasmiditan for treatment of acute migraine (i.e., migraine attacks). The company has just received funding to start Phase III clinical trials. Lasmiditan is a member of a drug class called “diptans.” These drugs penetrate the central nervous system and selectively target 5HT1F receptors in the trigeminal nerve pathway (the trigeminal nerve is a cranial nerve responsible for sensation in the face. It is believed to play a key role in migraine attacks).
  • Six clinical studies, including a Phase IIB trial, have been successfully completed. This is the only 5HT1F agonist being developed. Triptans (eg, sumatriptan, zolimitriptan, eletriptans, etc.) are 5HT1B 5HT1D receptor agonists. In addition, some are 5HT1F receptor agonists. 5HT1B receptors are located on blood vessels and are responsible for cardiac contraindications to triptans.

3. TI-001 (Oxytocin Nasal Spray)

  • Trigemina Inc. is conducting a Phase II study of TI-001 for the treatment of chronic migraine. Oxytocin is a peptide that reduces migraine-related inflammation. An injectable form of oxytocin has been available for more than 60 years, and nasal oxytocin (in a lower dosage than TI-001) is available in Europe.

Neurostimulation devices

These are devices that stimulate peripheral nerves or the brain itself in order to modulate headache. Some are already on the market for treating epilepsy, depression, and headache. Others are being developed specifically to treat migraine. Categories are:

Transcranial magnetic stimulation (TMS)

  • eNeura has an FDA-approved device (SpringTMS) to relieve the headache pain of migraine with aura. It’s a non-invasive, portable, battery-powered device that patients hold to the back of their head as soon as they notice symptoms. It delivers a quick, single, magnetic pulse to the back of the head.
  • This results in stimulation of the occipital cortex, which may reduce brain hyperactivity associated with migraine. It is now undergoing post-market, open-label studies that suggest it decreases migraine attacks.

Vagus nerve stimulation (VNS)

  • electroCore Medical makes a non-invasive VNS device called “GammaCore.” It’s a small handheld device in which patients can adjust the intensity themselves. It is used to deliver two, 90-second electrical stimulations to the neck over the vagus nerve.
  • It may work by sending signals to the brain that reduce levels of glutamate, which is a neurotransmitter in the trigeminal nerve that sends pain signals to the brain, resulting in headache. GammaCore has had positive results in studies for chronic migraine and cluster headache.

Supraorbital transcutaneous stimulation

  • This FDA-approved Cefaly device (made by Cefaly), is worn around the front of the head. It has an adhesive patch that is attached to the electrode that’s positioned mid-forehead. It delivers mini-electrical impulses to nerve endings of the trigeminal nerve (a nerve that has a branch ending in the forehead). This produces a tingling effect, which, when regularly repeated, has been shown to reduce the number of migraine attacks.

Occipital Nerve Stimulation

  • This involves surgically putting electrodes around nerves in the occipital region. The electrodes are connected to an implanted neurostimulation device. Neurostimulation is already in use for treating other types of pain. The devices have been shown to reduce the frequency and intensity of migraine attacks in chronic migraine patients for whom medical therapies don’t work.
  • Electrodes are implanted under the skin and over the occipital nerves, and attached via leads (thin wires) to a battery that is implanted in the chest. The physician programs the battery (using a handheld programmer) to deliver electrical charges when migraine attacks are about to begin. St. Jude Medical and Medtronic make neurostimulation devices that are under study for chronic migraine.

Sphenopalatine Ganglion Stimulation

  • The sphenopalatine ganglion (SPG) is a nerve bundle located deep in the face. Autonomic Technologies, Inc. (ATI) developed the Pulsante™ SPG Microstimulator System to provide on-demand SPG stimulation to relieve the acute severe pain of cluster headache by blocking the nerve signals that are thought to be responsible for the pain and autonomic symptoms associated with cluster headache. Cluster headache is a highly disabling headache disorder characterized by intense stabbing pain in the area of one eye, often accompanied by swelling, tears and nasal congestion. Attacks, each lasting 15 to 180 minutes, can occur multiple times a day.
  • The device is inserted through a small incision in the upper gum above the second molar and positioned at the sphenopalatine ganglion (SPG) nerve bundle. Patients control their own stimulation treatment, as needed, by turning on the Remote Controller and placing it on the cheek over the inserted device. It is currently in clinical trials in the US.

Behavioral techniques

A variety of behavioral techniques may be used alone or to augment the effects of pharmacologic treatment. Behavioral treatments; involve learning skills designed to train the body to be less “on edge” (e.g.:, relaxation training, biofeedback, and cognitive-behavioral therapy with a focus on managing stress) and skills designed to promote a healthy lifestyle, including getting adequate sleep, not skipping meals, regular exercise, and being aware of food, beverages, or other substances that may trigger or exacerbate a migraine attack.

The U.S. Headache Consortium (Silberstein, 2000) made the following recommendations pertaining to behavioral treatment for migraine:

  • relaxation training, thermal biofeedback combined with relaxation training, electromyography biofeedback, and cognitive behavioral therapy may be considered as treatment options for preventing migraine (Grade A Evidence); and
  • behavioral therapy may be combined with preventive drug therapy to achieve added clinical improvement for migraine (Grade B Evidence) (Campbell et al. 1999; http://www.aan.com/).

Relaxation training, biofeedback, and cognitive-behavioral therapy are specific techniques that can be effective for many patients. Each of them has a similar goal: to train the patient to have the skills to not be excessively aroused (that is, less stressed, tense, on edge) physically and mentally. Each of them provides the patient with skills to rapidly respond to life situations that can provoke stress, anxiety, or anger. They also provide the patient a skill they can use daily to help keep their body not being as stressed, tense, on edge in general. This helps the patient be less susceptible to getting a migraine.

These techniques are often used in combination, but take a slightly different approach to training the skill. In relaxation training, the patient learns to recognize how their body (especially muscle areas) feel when they are tensed versus relaxed. The patient then learns to breathe in a way that helps promote less tense muscles and learns when to recognize tension in daily life and apply relaxation techniques.

In biofeedback, the patient learns, by video and/or audio feedback, to recognize the difference in how their body feels when it is excessively aroused (that is, stressed, tense, on edge) versus when they are not. Thermal feedback of skin temperature (hand warming), and electromyography feedback (electrical activity from muscles of the scalp, neck, and/or upper body), are the most commonly employed biofeedback modalities The person then learns how to control their body’s internal arousal system (called the autonomic system) and applies those skills to be less stressed, tense, on edge in daily life. In cognitive-behavioral therapy, the patient learns to recognize stressful situations and learns skills to respond to the situation differently and over time, change how they view situations so they don’t provoke stress, anxiety, or anger. 

Other behavioral techniques, including yoga, meditation, and other psychological therapies In particular, yoga and meditation can increase vagal nerve activity, an important part of physical and emotional health.

There are no treatments in development targeting specific populations, however, there are existing treatments targeted to Menstrual Migraine (MM)

If severe MM cannot be controlled by standard acute and preventive treatment, hormonal therapy may be indicated. Successful hormonal or hormonal modulation therapy of MM has been reported with estrogens (alone or combined with progesterone or testosterone, combined OCs, synthetic androgens, estrogen modulators and antagonists). Progesterone is not effective in the treatment of headache or the symptoms of PMS. Extended-duration contraceptive regimens have been shown to be of more benefit than traditional regimens.

A new era for migraine relief

Jessica Ailani, MD, director of the MedStar Georgetown Headache Center, had been treating a woman for several years with Botox injections, a standard treatment to relieve frequent, debilitating migraine. The patient, a health care researcher, was doing okay but not great, so she asked if any other options might work better.

Ailani decided to try galcanezumab, a new medication in a class called calcitonin gene-related peptide (CGRP) inhibitors. A few visits later, the woman reported publishing three scientific papers in the past seven months — more than her output for the previous eight years.

“She said, that’s the difference — the cognitive clarity, being myself, being able to function. I can make a commitment because I know I’m going to feel good,” Ailani recalls. “She said I’m back to that person I was 20 years ago.”

For decades, science provided no major breakthroughs to migraine sufferers. But now research at teaching hospitals and elsewhere is finally offering hope to patients like Ailani’s, who sometimes experienced limited or even no success with earlier methods. A new type of drug approved by the Food and Drug Administration in recent years blocks a pain pathway associated with migraine. In addition, new devices use electrical or magnetic pulses to quell migraine-related brain activity. And work continues as researchers seek more answers to aid the 38 million migraine sufferers in the United States.

“Gone is the day that we just use treatment options that were approved for other indications for our migraine patients…. We are now in an era where we understand what is happening in migraine inside of the brain.”

Amaal J. Starling, MD, Mayo Clinic

Importantly, the new discoveries are the first treatments designed specifically for migraine. Previous drugs had been developed for conditions such as epilepsy or high blood pressure and recruited into the battle against migraine.

“Gone is the day that we just use treatment options that were approved for other indications for our migraine patients in clinical trials and find that they might be effective,” says Amaal J. Starling, MD, a neurologist at the Mayo Clinic in Arizona. “We are now in an era where we understand what is happening in migraine inside of the brain. Based on our understanding, we’re designing treatment options.”

These new treatments “all are testament to the fact that if you dig at it enough and start to understand what’s important in the disease, you can actually target a therapy to that,” says Peter Goadsby, MD, a professor of neurology at the University of California, San Francisco, School of Medicine. “It’s a really exciting time to be in neurology broadly and particularly in headache medicine — to have people whose lives have been blighted by the problem where it’s just turned around. They come back and their lives have been transformed. The look on their faces is priceless.”

The burden of migraine

Migraine is not just about headaches. Attacks can include symptoms such as throbbing pain, nausea, vomiting, and acute sensitivity to light and sound. They may be preceded by aura — nerve-related symptoms such as flashes of light, blind spots, difficulty speaking, and tingling in the face, arms, or legs. Migraine may last four hours or three days. Attacks may occur rarely or several times a week.

According to the American Migraine Foundation, 1 in 5 U.S. women have migraine. So do 1 in 16 men and 1 in 11 children. Because migraine is common and debilitating, the burden on personal wellness and economic productivity is staggering. In 2016 the combination of medical costs and lost productivity due to migraine in the United States totaled $36 billion, according to a study published in the American Journal of Managed Care.

“There are so many people who are brilliant and successful who have had to walk away from work because this disease has completely destroyed them.”

Jessica Ailani, MD, MedStar Georgetown

“It takes careers away from people,” says Ailani. “You know, they could have been a teacher and now they’re an assistant. They could have been a professor and now they’re the janitor in the hallway. There are so many people who are brilliant and successful who have had to walk away from work because this disease has completely destroyed them.”

For a long time, researchers didn’t know how migraine worked. “The understanding used to be that migraine was a blood vessel disorder — they dilated and they constricted,” says Stephen Silberstein, MD, director of the Jefferson Headache Center of Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia. “But now we know that blood vessels are innocent bystanders.” Instead, Silberstein explains, it’s primarily a disorder of the trigeminal nerve and its connections. That nerve wraps around the eyes, forehead, and mouth, and among other roles, affects sensation in a person’s face.

Thirty years ago, Goadsby did some of the earliest work establishing that abnormal nerve activity preceding migraine released a flood of proteins called CGRPs, which produced pain in some people with migraine as the compound latched on to a neural receptor. This CGRP activity could be measured by increased concentrations of the peptide in the blood. In fact, administering CGRP could induce migraine in many patients. Understanding this CGRP pathway opened the door to new migraine treatments.

Locking out CGRPs

The newest drugs for migraine block the effect of CGRP by preventing it from grabbing its neural receptor. Some of these drugs latch onto the CGRP. Others lock onto the receptor. Both block the action of CGRP.

These drugs fall into two additional categories.

First are several small-molecule compounds known as gepants. “They compete with CGRP to jump on the receptor,” Goadsby explains. “They have a half-life that’s measured in hours. If you take a gepants, the effect of it is gone tomorrow.” FDA approval of several gepants is pending.

“The major thing I have seen — and we have data — is that these drugs often work when other drugs have failed. That’s the game changer.”

Stephen Silberstein, MD, Sidney Kimmel Medical College

Second are monoclonal antibodies, a collection of large proteins. “They live in the body for weeks, up to a month, and they either latch onto the antibody or latch onto the CGRP or the CGRP receptor,” says Goadsby. Three monoclonal antibodies won FDA approval last year, and a fourth is being reviewed.

“The major thing I have seen — and we have data — is that these drugs often work when other drugs have failed,” says Silberstein. “That’s the game changer. They’re an alternative.” For example, one CGRP study with patients who were unsuccessfully treated in the past found that 30% had their monthly migraine days cut in half.

For “super-responders,” perhaps 20% of migraine patients, CGRP inhibitors can be life-changing, notes Starling. Unfortunately, they don’t work for everyone, suggesting a different pathway is at work in those patients.

One potential option is lasmiditan, recently approved by the FDA for acute migraine treatment. It targets a second pathway that plays a role in migraine, the serotonin 5-HT1F receptor. It works much like triptans, a much older class of drugs. Because it is more specific to the pathway relevant to migraine, it doesn’t constrict blood vessels, as the old drug does, so it can possibly be used for patients with coronary artery disease, a history of stroke, or uncontrolled high blood pressure.

Says Ailani, “We need more things like this. We need to figure out those other pathways and how do we shut these switches off so we make people feel like the person they were supposed to be.”

Pulsing devices to the rescue

Also new in migraine treatment are neuromodulators, devices that use electrical or magnetic pulses to calm an electrical wave associated with migraine called cortical spreading depression.

“When a migraine attack starts there is this abnormal electrical activity that travels over the brain surface area,” Starling explains. “And so the theory was, if we have a device that stops cortical spreading depression, then maybe we can stop a migraine attack once it has already started.”

The FDA recently cleared several devices for treatment of acute migraine and prevention of migraine. One, the single-pulse transcranial magnetic stimulation device, is roughly the size and shape of a binocular case. Starling demonstrates by holding it to the back of her head with both hands and pressing two buttons. The device makes a sharp click as it sends a magnetic pulse into the scalp. Other than the noise, there’s no physical sensation, she says.

Starling has been recommending the device for daily use to reduce the frequency of migraine —“four pulses in the morning, four pulses at night — and they could also use it as needed,” she says.

Such devices have several advantages over other treatments. They are noninvasive and seem to have minimal side effects, if any. They can be used whenever needed without contraindications for other drugs or medical conditions such as autoimmune conditions, heart disease, or pregnancy.

There’s a big drawback, though: The devices are pricey, even to rent, and not usually covered by insurance.

Starling says neuromodulation has success similar to CGRP inhibitors. “In general it is effective in about 50% of patients,” she says. “And in that 50% of patients, it has at least a 50% reduction in migraine days.”

Patients often ask Starling why no one treatment will work for every person. “The thing is, migraine is a genetic disease. We have identified about 40 genes that have associations with migraine. And everybody has a little bit of a different combination of these different gene mutations,” she explains.

“Everybody’s migraine is different, and so not one treatment option is going to be effective for everyone,” Starling notes. “I dream about the day where I can do a genetic analysis on somebody and then I can say, based on your genetic analysis this is the treatment option that’s going to work for you.”

Other options

Other treatments are being investigated, such as the anesthetic ketamine, which has been proven effective in treating persistent depression. “It may act as a neuromodulator,” says Silberstein. Treating patients with ketamine for four to five days can appear to break a cycle of chronic migraine, he says. Ketamine for migraine is now being tested in a pilot study.

There’s also evidence that some new treatments work synergistically with older treatments, such as Botox injections, says Silberstein. In particular, he says, adding antibodies to Botox treatment appears more effective than antibodies alone.

Among the standard treatments that can improve the effectiveness of any new drug or device are lifestyle changes. A study currently underway at Vanderbilt University Medical Center is exploring the effects of lifestyle modifications, such as avoiding certain foods and improving sleep, on one type of migraine.

“Adequate sleep is important,” says Silberstein. “If you don’t get it you need to find out why.” Sleep apnea is “a major aggravating factor for migraine and health in general,” he says. “That’s one thing that’s frequently missed and easily corrected.”

Regular exercise and relaxation techniques such as yoga and meditation can help stave off migraine attacks, he says. “You can’t avoid stress, but you can handle it better. No matter what, these are good things to do.”

Although Silberstein believes “diet is overblown” as a remedy, migraine sufferers should limit monosodium glutamate and the nitrites and nitrates found in processed meats. Otherwise, he says, “Healthy eating. Don’t get drunk. Don’t starve. Don’t withdraw from caffeine.”

Diets that are low-fat, plant-based, and high in omega 3 fatty acids have been shown to reduce the pain of migraine, according to the Physicians Committee for Responsible Medicine. Elimination diets are useful in identifying foods that may trigger migraine in patients, says the PCRM. Also, carrying too little weight is associated with greater risk of migraine, and carrying excess weight is even more problematic.

As scientists continue to seek additional answers to what works well for migraine, it’s important that patients who are suffering see their doctors, even if treatments in the past produced little or no success, experts note.

“Things are very different right now,” says Ailani. “It’s an exciting time in our field. I think that this is a great time to see patients who have headaches because we have so much to offer them.”

Five Ways to Stop a Migraine Before it Starts

Chances are you or somebody you know has suffered from a migraine headache before. An estimated 37 million people in the United States – roughly the entire population of California – experience migraines regularly. They usually begin as a dull ache that quickly spirals into an intense, pulsating pain. Migraines can last anywhere between a few hours and a few days and are often accompanied by nausea, vomiting, dizziness and extreme sensitivity to light and sounds.

A life with migraines can be a struggle. But we have some good news for migraine sufferers.

Dr. Gwyneth McCawley, neurologist with Mercy Clinic Neurology and Headache Center in St. Louis, has five straightforward steps that can help you avoid migraines and get back to living your life to the fullest.

  1. Get your beauty sleep. Catching enough zzzs is critical for keeping migraines at bay. A sleep-deprived week followed by a Saturday spent sleeping-in could have the potential to ruin your weekend with a headache. Dr. McCawley recommends staying in a routine by going to bed at the same time every night and waking up at the same time every morning.
  2. Eat. Skipping meals can change hormones in your body, another migraine trigger. Don’t go more than six or seven hours without food and be sure to include protein, leafy greens and vegetables. For snacks, think string cheese, yogurt, trail mix with nuts and fruit, granola bars or protein bars.
  3. Cut the caffeine. If you can’t go without it, try limiting yourself to no more than 100-200 mLs a day. For example, a cup of coffee has about 100 mLs, soda has 60 and black tea has 30-40. Too much caffeine can not only bring on a migraine, it can make you have a migraine more often.
  4. Stay hydrated. Drinking plenty of water decreases pain perception in your brain. If you get dehydrated, it can set off a migraine.
  5. Exercise. Aerobic activity has been shown to protect against migraines, so whether it’s power walking or weight lifting, your heart rate needs to be elevated for 30 minutes to get the full effect.

Migraine aura: What you need to know

Conditions

By Beth Longware Duff; reviewed by Gary Heiting, OD

What is a migraine aura or a migraine with aura?

A migraine aura is a warning sign that a migraine headache is about to begin. It usually involves visual disturbances that occur in just one eye and range from flashing lights and zigzag lines to blind spots and blurred vision.

Trouble speaking and numbness can also be part of a migraine aura. Migraine auras also can be sensory or olfactory as well.

Most migraine auras last less than an hour before the head pain starts.

This is known as migraine with aura.

How common is migraine with aura? Less than a third of migraine sufferers experience aura.

Here’s what you need to know about migraines with and without auras:

What is a migraine?

Migraine in a neurological condition that is characterized by often incapacitating symptoms including severe, throbbing and recurring pain that’s usually centered on one side of the head.

Other disabling symptoms of a migraine are nausea, vomiting, dizziness, tingling or numbness in the extremities or face, and extreme sensitivity to sound, light, touch and smell.

Migraine affects about 1 billion men, women and children worldwide and approximately 40 million Americans.

Migraine headaches can last up to three days and produce moderate to severe pain.

Migraines are most common between the ages of 18 and 44, and they affect women disproportionately. Eighteen percent of American women suffer from migraines, compared to 6 percent of men and 10 percent of school-age children.

There is a strong genetic link for migraines, with about 90 percent of sufferers reporting a family history of these headaches.

Migraine is a “diagnosis of exclusion,” which means it is reached by a process of elimination since there is no test or biomarker to confirm its presence.

Just as every person is unique, so are migraine headaches. Migraines differ from person to person, and migraines also can present in different ways and with different symptoms in the same person.

SEE RELATED: Can dry eyes cause migraines?

What is a migraine aura?

Migraines fall into two basic categories: migraine with aura and migraine without aura.

So, what is a migraine aura and is it dangerous?

“Aura typically is benign in the sense that there is no pain attached to the aura itself. It’s a visual event, a precursor to something much worse,” says Cathy Glaser, executive director of the Migraine Research Foundation.

“The aura is actually during the migraine, but it’s before the other symptoms come,” Glaser adds. “You may feel a little off, and then you get the aura and you know you’re getting a migraine, but you don’t know how bad it’s going to be.”

A migraine that begins with head pain (without visual disturbances or other symptoms of aura) is called migraine without aura.

The majority of migraine sufferers do not experience an aura beforehand, so they receive no early warning of the impending headache until the pain begins.

How to reduce migraine triggers

There are no medications specifically for migraine aura, and no dependable way to prevent it. However, there are steps sufferers can take to try to control their migraines.

Lifestyle changes (also known as complementary treatment) that eliminate migraine triggers often can help.

“We know that the migraine brain is a very sensitive brain that likes things to remain the same. So you need to eat regularly. If you skip a meal, that’s a trigger,” says Glaser.

“You need to sleep regularly, and not just catch up on your sleep on the weekend. You need to hydrate because dehydration is also a trigger,” she adds.

“Keep your stress levels as low as possible and learn how to deal with stress. If you can live that way, then you’re raising the threshold to get a migraine,” Glaser says.

Migraines also can be triggered by environmental factors that can be controlled to one degree or another. These include bright or flickering lights, pollution, changes in altitude, air pressure, strong smells and motion sickness.

Weather changes — such as high or low humidity, sudden or drastic changes in temperature or barometric pressure — also can bring on a migraine headache.

In women, fluctuations in hormones related to pregnancy, oral contraceptives, menstruation and menopause can trigger migraines.

Contrary to some beliefs, Glaser says there is no strong scientific evidence linking migraines to specific foods.

“There are very few food triggers, and none that are universal. Sometimes doctors will put people on an elimination diet just to see if things improve,” she says.

Alcohol and caffeine are two substances that she recommends be limited.

In addition to eliminating migraine triggers, simple relaxation techniques are often recommended for controlling migraines. These include biofeedback and other forms of relaxation training that can reduce stress that may act as a trigger for migraines.

Regular aerobic exercise like cycling, walking and swimming can also help reduce tension and prevent migraines.

SEE RELATED: Ocular and visual migraines: What’s the difference?

Treatments for migraine

Several medications are available to help relieve the pain of a migraine headache (but, as mentioned above, these will not eliminate a migraine aura). These medications are categorized as abortive treatment and preventive treatment.

Abortive (also called acute or pain-relieving) medications are over-the-counter (OTC) and prescription drugs that are taken at the first sign of a migraine to stop or reduce pain and other symptoms.

For sufferers of migraine with aura, these medications should be taken as soon as the aura begins.

Designed to work quickly to alleviate nausea and vomiting, the sooner these medications are taken, the more effective they are at treating the migraine.

Abortive medications are varied and can be taken by mouth, skin patch, nasal spray or self-injection.

Abortive migraine therapy includes prescription triptans, dihydroergotamines (ergots) and narcotic opioids containing codeine.

The common OTC pain relievers aspirin or ibuprofen, and migraine relief medications that combine caffeine, aspirin and acetaminophen (Excedrin Migraine, for example), also can provide relief.

Preventive migraine medications are taken daily to prevent migraines from occurring. This therapy reduces the number of attacks, lessens the intensity of pain and prevents the onset of future migraines.

Preventive migraine therapy includes prescription high blood pressure medications like beta-blockers and calcium channel blockers, antidepressants, anti-seizure medications, and Botox.

Some migraine sufferers end up taking both abortive and preventive medications for maximum control of their migraine attacks.

As with other medical conditions, treatment decisions for migraines (with or without migraine aura) should be made in consultation with your primary health care provider.

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Page updated August 2019

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Medications to Stop an Active Migraine

Treatment of migraine typically focuses on one of two areas: easing the symptoms of a migraine after it starts, or preventing a migraine from occurring. There is no cure or medication that keeps all migraines from occurring.

In most cases, a medication can be found that will help relieve symptoms of a migraine once it begins. A number of medications are designed to halt a migraine within about 2 hours after onset. However, finding the best treatment to stop a migraine may be a process of trial and error.

Both prescription and over-the-counter medications may be used to treat an ongoing migraine.

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Eye Drops, Patches, and Other Forms of Migraine Relief

Because nausea and vomiting commonly accompany a migraine, medications are typically offered in a variety of forms that are easy to swallow or do not need to be swallowed, such as:

  • Dissolving tablets
  • Eye drops
  • Nasal sprays
  • Patches
  • Rectal suppositories
  • Self-administered injections

If a problem occurs when taking one form of medication, it may be worthwhile to ask the prescribing provider if it is available in another form.

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Medication Precautions to Consider

Certain medications to treat migraines are not advised in all circumstances. For example, a specific medication may not be recommended for:

  • Children
  • Women who are pregnant or planning to become pregnant
  • Women who are breastfeeding
  • Those with serious medical conditions in addition to migraine headaches

This article includes brief information on potential risks and side effects. Individuals are advised to review these issues in detail with the health care provider and pharmacist.

Triptan Medications

The first choice for stopping a migraine is usually a group of medications called triptans. Triptans treat the pain, nausea, and vomiting common in migraines. Most people who take a triptan medication at the first sign of a migraine experience pain relief within 2 hours.

Experts are not certain exactly how triptans work; some believe triptans ease swelling of the blood vessels. These are among triptans that may be prescribed:

If one type of triptan medication is not effective, another may be prescribed. Medical professionals may recommend a specific type of triptan for certain conditions.

Those with heart disease, risk factors for heart disease, or peripheral vascular disease are usually advised to avoid triptans. An uncommon common side effect, serotonin syndrome, may include a racing heartbeat, confusion, hallucinations, fever, problems walking, and diarrhea. Anyone with these symptoms should see a health care provider without delay.

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Ergotamine Medications

If triptan medications are not helpful, ergotamine medications may be prescribed to halt a migraine. This group of medications is thought to help reduce the pain and other symptoms of a migraine by narrowing the brain’s blood vessels. These are some ergotamine medications for migraines:

  • Dihydroergotamine (Migranal) is a nasal spray designed to reduce pain within 2 hours and offer major relief within 4 hours. A key benefit is that it usually prevents further migraines for the next 24 hours.
  • Dihydroergotamine mesylate (DHE 45) is a self-administered injection that eases nausea and sensitivity to light and sound as well as pain. Dihydroergotamine mesylate is sometimes given intravenously in emergency rooms to relieve migraine symptoms.
  • Ergotamines with caffeine go by the brand names Cafergot and Migergot. Cafergot and Migergot are both available as suppositories, and Cafergot is also sold in tablet form.

Ergotamines can have serious side effects, and are not advised for those with heart or circulation problems. In rare cases, fatal heart problems have occurred.

Additional Medications for Acute Migraines

Other medications to ease the pain of migraines include beta blockers and nonsteroidal anti-inflammatory drugs, or NSAIDS:

  • Beta blockers. Beta blockers, such as the eye drop timolol (Blocadren) are designed to work by opening up blood vessels, improving blood flow.
  • Non-steroidal anti-inflammatory drugs (NSAIDs). Available in liquids, tablets, and other forms, NSAIDs are commonly taken for migraine pain. Options include but are not limited to aspirin, ibuprofen, and naproxen sodium.

Medications to relieve a migraine should be taken only when a migraine is occurring, and not used to treat other types of headaches. If a preventive medication is sought, an experienced medical professional can explain the options.

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