Headache

 

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General migraine recommendations  

   

According to the 2019 Global Burden of Disease Study by the World Health Organization, migraine ranks second among all causes of years-lived-with-disability in patients of 15-49 years old worldwide. We understand migraine is a severe illness impacting your life, and we appreciate you coming to us for better migraine management. Here are some general recommendations for migraine.   

Headache Diary:

A headache diary can be a helpful tool in tracking your headache symptoms and identifying triggers. Here's how you can keep a diary:

• Get a notebook or use a digital application that you can easily access.

• Write down the date, time and duration of each headache.

• Record your symptoms such as the location of the headache, the level of pain, and any associated symptoms such as nausea or light sensitivity.

• Record any medications you take to treat your headache, including the dose and time taken.

• Note any potential triggers such as certain foods, stress, changes in weather, or certain activities.

• Review your diary regularly, at least once a week, and look for patterns in your headaches. This will help you and your healthcare provider to identify triggers and find the most effective treatment for your headaches.

• Be sure to bring your diary with you to all of your healthcare provider appointments so they can review it and make the best recommendations for your care.

Remember, keeping a headache diary is a simple and effective way to track your symptoms and identify triggers. 

Treatment of migraine typically entails medications, lifestyle modifications, and non-pharmacological management. Here, we discuss medicine, nutraceuticals, and non-medication ways to manage your migraine.  

   

Preventive medication:  

• If you have migraine more than 4-6 days a month, you may need a migraine preventive medication. Preventive medications include CGRP functional blocking monoclonal antibody (e.g., erenumab, fremanezumab, galcanezumab, eptinezumab), gepant (e.g., rimegepant, atogepant), antiepileptic (e.g., topiramate, valproate), antihypertensive (e.g., propranolol, timolol, candesartan, lisinopril), antidepressant (e.g., nortriptyline, amitriptyline, duloxetine, venlafaxine), and onabotulinumtoxinA. It may take 6-8 weeks to start seeing an effect. The dose may need to be optimized over 3-6 months. Don't be surprised if you don't notice any improvement during the first few weeks of taking a new medication. As long as you do not have any significant side effects, it would be best to continue taking the medication as prescribed until your next follow-up visit. If a prescription does not benefit after a couple of months or causes major adverse effects, we will try something else.  

• All medications have the potential to cause side effects. For most people, side effects are mild and may go away after a few weeks as your body adjusts to the medication. Please let us know if you have any unexpected or bothersome side effects.  

• Certain branded medications, such as Trokendi, CGRP monoclonal antibody (mAb), gepant, and Botox, require prior authorization. Some insurance companies cover only one of them. There may also be saving programs to reduce your copays.    

• Some medications may not be safe during pregnancy or breastfeeding. For example, topiramate, sodium valproate, CGRP mAb, and gepant are not recommended during pregnancy. It is important to use contraception while on such medications. Doses of topiramate greater than 200 mg total per day may also decrease the effectiveness of hormonal contraception.  

 

Abortive (as needed rescue medicine):  

• In addition to over-the-counter pain killers (e.g., Tylenol, Advil, Aleve, Excedrin), acute medications include ergot, triptan, gepant, ditan, NSAID, and neuroleptic. Each class of abortive has different adverse effect profiles. For example, DHE and triptans are contraindicated if you have coronary artery disease, coronary vasospasm, history of hemiplegic/basilar migraine, uncontrolled hypertension, Raynaud's disease, or peripheral vascular disease. Triptans and ditan may cause rebound headache if used too often. Gepants are typically well-tolerated with minimal risk for rebound headache but are not always covered by insurance. Ditans may cause driving impairment. NSAIDs, such as Aleve, Advil, aspirin, or nabumetone, may cause gastric irritation or bleeding. Neuroleptics (e.g., prochlorperazine, metoclopramide, promethazine, haloperidol, olanzapine, chlorpromazine) may be associated with restlessness and involuntary movements. Nerve block and trigger point injection can also be used for temporary pain relief.  

• Migraine can worsen over time if certain abortive medications (e.g., ergotamine, triptan, opioid, barbiturate-containing pain killer, NSAID) are used too frequently. This is called medication overuse (adaptation) headache, also called "rebound headache ."It is essential to limit the number of days you use these abortive medications to avoid this. In general, we recommend not using more than 10-12 days per month (you can use more than one medication on the same day - these count as 1 day of treatment). If you need abortive medications more often than recommended by your provider, please ask about trying a different medication or treatment strategy. Gepants, ditans, and neuroleptic usually are not associated with rebound headache.  

• Please keep a calendar of your migraine and bring it to every appointment. It can be as simple as marking off the days that you had a headache, or you can write the maximal headache severity from 0-10 (or "mild," "moderate," "severe"). Preventive medications begin working slowly; being able to review your headache frequency and severity on a calendar is a beneficial way to see if a medication is starting to work. It is also good to write down any abortives you used that day. This will help you keep track of which abortives work best for you and allow you to monitor how frequently you are taking them. Some patients find it helpful to keep track of various headache triggers (e.g., insomnia, stress, caffeine use) to look for patterns. There are apps such as Migraine Buddy or Ctrl M health that you can download to your phone. If you are interested in using N1-headache, which analyzes your headache pattern and generates a trigger map, please request an invitation email from us.  

 

Non-prescription medications known to help migraine:  

Magnesium, riboflavin, and Coenzyme Q10 are all used to treat headaches because they have been shown to have a positive impact on the body's ability to manage and prevent headaches. Magnesium is important for maintaining healthy nerve and muscle function, and a deficiency in magnesium can lead to headaches. Riboflavin, also known as Vitamin B2, is important for maintaining healthy energy levels in the body and can help to prevent migraines. Coenzyme Q10 is an antioxidant that helps to protect the body's cells from damage and can also help to prevent migraines/headaches. Taking these supplements can help to improve your overall health and reduce your risk of headaches. However, it's always important to check with your healthcare provider before starting any new supplement regimen.

• CoQ10 100-300 mg/day. Some may need 800mg daily. It may improve energy but shop around for a good bargain as this can be pricey.  

• Riboflavin (VitB2) 200 mg twice daily. It may improve energy but may turn your urine yellow.  

• Magnesium glycinate (gluconate) 500-1000 mg/day in single or divided doses. Magnesium oxide is more prone to loose stools/diarrhea.  

• Butterbur, Boswellia extract, vit D (keep level >50), vit K2, methyl-folate, methylcobalamin, probiotics may also be beneficial.  

 

You can pick one or two of these to start. It can take 3 months to become effective. It is safe to take it all together and with your other medications. Combination pills can be found online (e.g., Migra-eeze, Preventa-Migraine, etc.) To explore verified nutritional support (e.g., riboflavin or B2, magnesium, Coq10, or butterbur) for migraine. Keep in mind these supplements are not studied as rigorously as medications. They are not entirely risk-free.  

 

Non-Medication Ways to Manage Migraine:  

• Regular exercise has been shown to decrease headaches just as effectively as medication. Try to do some physical activity at least 3 days a week—a combination of stretching, aerobic, and strengthening exercises. If you don't already exercise, start simple with walking for 20-30 min. Yoga or Pilates are great ways to stay active and decrease tension in the neck, shoulders, and back. Avoid neck cracking. 

• Eat a healthy diet (americanmigrainefoundation.org/resource-library/migraine-and-diet/). Avoid skipping meals (a common headache trigger). Stay well-hydrated (~1 gallon/day). Limit caffeine (no more than 2 cups of coffee a day). High omega-3 diet or anti-inflammatory diet may be helpful. Adherence is critical; discussion with a registered dietician can help.  

• Reduce or avoid common food triggers: MSG (Chinese food, any snack with orange powdery cheese [Doritos, Cheetos, etc.], Italian dressing), processed food, aged meats and cheeses, nitrates (lunch meats, hot dogs), red wine, chocolate, alcohol, excessive caffeine. 

• Stick to a regular sleep pattern. Sleeping too much or not enough and changing the time you go to bed and wake up are all common headache triggers. Practice sleep hygiene or talk to a therapist about cognitive behavior therapy if needed. Treat sleep apnea, if any.  

• Keep good ergonomics in your working area to avoid unnecessary neck or upper back strains, which can often trigger migraine. Strategy to reduce neck pain (e.g., physical therapy) or TMJ pain (e.g., bite guard) should be implemented if needed.   

• How these recommendations affect your body and migraine vary individually. Managing migraine is a life journey, and hopefully, this information empowers you to find the strategy that best fit your need.  

Changes in Headache Symptoms: When to be Concerned

• Neurological symptoms that are new or accompany headache

• Sudden onset of headache

• Positional components—it feels better when they lay down and worse when they’re upright, for example

• New onset of headache in pregnancy

• Progressive changes in headache, where headaches are continually worsening

• Significant vision changes

• Weakness

• Numbness

• Trouble speaking or concentrating