When the pounding in your head starts to interrupt your life, it's time to talk to a healthcare professional about what your options are. Treatment for chronic migraines can be split into three categories: preventative treatments, acute (also called "abortive") treatments, and complementary treatments.
“Most people with chronic migraines are taking both a preventive medication and have an acute medication to use as needed,” according to Mason Dyess, DO, a general neurology and headache medicine physician at Ochsner Medical Center.
Medications To Prevent Chronic Migraine
Preventive medicines are “medicines that you would take scheduled on a daily basis or injections on a monthly basis,” Dr. Dyess explained. “Whatever your regimen is, it’s helping you actually prevent headaches from occurring.”
Blood Pressure Medications
Blood pressure medications, like beta-blockers, can be "very effective" at preventing migraines, Dr. Dyess said. "We typically start out at doses lower than a typical patient would use for actual blood pressure," Dr. Dyess explained. As far as why they work, Dr. Dyess said there's a concept called cortical spreading depression (CSD)—a wave of activity across the surface of the brain—and healthcare professionals think these medicines can interrupt the spreading process of a migraine.
Amitriptyline is often used to prevent migraines, but side effects like nightmares, dry mouth, and extreme sleepiness mean it’s not a good fit for everyone, according to MedlinePlus. Another option is venlafaxine (Effexor), a different type of antidepressant. Each is considered “probably effective” in migraine prevention, according to a statement from the American Headache Society published in 2021 in the The Journal of Head and Face Pain.
Anticonvulsants, such as topiramate or gabapentin, may be tried as preventative migraine therapy, according to the American Migraine Foundation. “We think that part of the issue with migraines is that your nerves become hyperexcitable, meaning that they fire more easily and become more irritated easily,” Dr. Dyess said. “We think that these anticonvulsants help calm the nerves and prevent them from being activated and causing more pain.” But side effects include skin rash, weight changes, and sedation.
Botox injections are approved specifically for chronic migraine sufferers, according to Johns Hopkins. On a basic level, botox “decreases sensory input around the face and neck,” said Robert Cowan, MD, professor of neurology and chief of the division of headache medicine at Stanford University. But there may be more to it than that. “We also think that chemically Botox helps dial down inflammation,” Dr. Dyess added.
Calcitonin Gene-related Peptide (CGRP) Inhibitors
Studies show that blood levels of calcitonin gene-related peptide (CGRP), a chemical messenger, are elevated during a migraine attack, according to a 2017 review in the Journal of Headache and Pain. That observation has led to two classes of CGRP blockers.
Monoclonal antibodies. Drugs like Aimovig, Ajovy, and Emgality block the effects of CGRP, according to the US Food and Drug Administration (FDA). Injected on a monthly or quarterly basis, the effects of these medicines can last for months, and they’re well-tolerated by most people—the most common side effect is pain at the injection site, per the American Migraine Foundation. Another monoclonal antibody, Vyepti, was approved in 2020 as the first intravenous (IV) treatment for migraine prevention, according to the American Headache Society.
CGRP receptor antagonists. These oral medicines work by stopping the inflammation that leads up to a migraine, Dr. Dyess explained. Nurtec ODT is a CGRP receptor antagonist that is the only one approved both as a preventive and acute medicine, according to the American Headache Society. Common side effects include nausea, stomach pain, and indigestion.
What Are Chronic Migraines? Neurologists Describe the Causes and Treatments
Medications To Treat Chronic Migraine
There are a few options for knocking out a migraine when you're in pain. "The acute medications are supposed to be employed at the very first sign of migraine. So you start having pain, you take the medicine," Dr. Dyess explained. "It, in theory, will help to eliminate the headache in a timely fashion so that you can go about your day."
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Many NSAIDs like aspirin, ibuprofen, and acetaminophen are available over the counter, which makes them a convenient option, according to the American Migraine Foundation. NSAIDs are typically used for mild headaches and can irritate the stomach and cause digestive issues like ulcers and gastrointestinal bleeding.
Triptans are one of the main headache-specific drugs recommended by healthcare professionals for chronic migraine, according to the American Migraine Foundation. Common brands include Imitrex (sumatriptan) and Maxalt (rizatriptan). Triptans work by stimulating serotonin, reducing inflammation, and constricting blood vessels, according to the National Headache Foundation. They’re most effective when taken early on in a migraine attack.
Dihydroergotamine (sold under the brand name Migranal) is available as a nasal spray or an injection, and it’s most effective when taken at the very start of a migraine that would otherwise last longer than 24 hours, according to MedlinePlus. Dihydroergotamine tightens the blood vessels in the brain and prevents the release of certain substances in the brain that cause swelling. Side effects include tingling or pain in the nose and throat, nosebleed, nausea, vomiting, and more.
CGRP Receptor Antagonists
Another CGRP receptor antagonist that is approved for the acute treatment of migraine is Ubrelvy (ubrogepant), according to the FDA. In drug trials, CGRP receptor antagonists have been shown to reduce pain, nausea, and light sensitivity within two hours. Ubrelvy’s side effects include nausea, dry mouth, and excessive sleepiness.
For people who haven’t found success with triptans, ditans may be an option. These drugs are believed to work by targeting a certain type of serotonin receptor on nerves that transmit headache pain, according to Harvard Health Publishing.
Reyvow (lasmiditan) is the first drug in its class. In clinical trials, substantially more people experienced migraine symptom relief within two hours versus those who took a placebo. Common side effects include dizziness and sleepiness.
“Nausea is a very common migraine complaint,” Dr. Dyess said. “So having a nausea medicine is very helpful.” But these medicines might help beyond reducing nausea, Dr. Dyess said. The way these drugs work may also help “shut down the migraine,” Dr. Dyess said. Options include metoclopramide and prochlorperazine, according to a 2018 review in American Family Physician.
Complementary and Alternative Treatments
If you've had chronic migraines for long enough, you've likely been recommended a host of different supplements. Unfortunately, most are ineffective at best. "If you were to Google supplements for migraine, the vast majority of those supplements do not have significant amounts of research behind them," Dr. Dyess said.
But complementary treatments are a viable option for some people. "The challenge is that these require active engagement on the part of the patient, and results are not typically immediate as they can be with some of the pharmaceuticals," Dr. Cowan said. "A lot of this hinges on patient preference."
Magnesium is among the few complementary treatments for chronic migraines that have shown promise. “It’s been proven safe in a variety of settings for headache,” Dr. Dyess said. It seems to help people who have migraines with aura in particular, and people with menstrual-related migraines, according to the American Migraine Foundation. It’s also safe for use in pregnant people, which is not true for some migraine medications.
There’s some evidence that high doses of riboflavin (B-2) reduces the number of migraines by about two migraines a month, according to MedlinePlus. Additionally, if you take riboflavin with other vitamins and minerals, this may reduce the amount of pain a migraine can cause.
Coenzyme Q10 (CoQ10)
A review and analysis of six small studies from 2020 in BMJ Open found no significant reduction in migraine severity with CoQ10 supplementation. But the compound may have other benefits. The duration and frequency of migraines with CoQ10 was significantly reduced compared with a control group.
Remote Electrical Neurostimulation (REN)
Nerivio, a wearable REN device, delivers electrical pulses to nerves in the upper arm. It’s believed that the brain responds to those signals by activating the body’s own ability to squelch pain in another part of the body, according to a study from 2021 published in Pain Reports. This non-pharmaceutical treatment may be a viable alternative for people with chronic migraine. The American Headache Society found that REN may reduce medication-overuse headaches.
Mindfulness, Biofeedback, and Other Awareness Techniques
“Migraines are very stressful when they’re happening. They’re very stressful on your family and your family dynamics that take a huge toll in your life,” Dr. Dyess said. Cognitive behavioral therapy, mindfulness, and even biofeedback (which teaches patients to monitor and control their heart rate) can help people manage stress and deal with the effects of migraine. “A lot of people use it as a way of dealing with the pain in real-time,” Dr. Dyess said.
Bottom line: Stay in conversation with a healthcare professional when it comes to complementary techniques. "I'm always open to trying whatever works to control their pain and control their migraines as long as it's safe," Dr. Dyess said.
A Quick Review
The pain of a migraine is typically something that can't be ignored. There are preventative, acute and complementary treatments available, all depending on the severity and frequency of your migraines. These medications may not be right for every person. Talk to a healthcare professional about your options to treat your migraine symptoms.