Management of Migraine

Migraine management involves identifying and avoiding triggers, using medication for acute attacks and prevention, and adopting lifestyle changes to reduce frequency and severity.

1.   Preventative

Preventative migraine medication is used in an attempt to reduce the frequency and severity of anticipated attacks. However, these drugs are unlikely to prevent attacks altogether and will not cure the underlying cause.

The goal of preventative treatments is to reduce the frequency of your migraine attacks. They are normally prescribed in one of the following circumstances:

  • If you suffer from more than two or three attacks per month
  • If your attacks are particularly severe or disabling and do not respond well to acute treatments
  • To break the cycle of attacks
  • If your attacks follow a regular pattern (e.g. around the time of menstruation)
  • If you suffer from rare forms of migraine such as basilar or hemiplegic migraine

Preventives are taken daily for a period of six to twelve months and while they rarely actually prevent attacks altogether, their success rate of about 50-60% means that it is likely you will experience at least some benefit. Preventatives will not be beneficial in treating an attack once it has started. Acute treatment is then necessary.

Some preventatives work better in one person than in another, so if one does not work well, it does not mean that another will not work.

  • a.    Non Specific

    These are medications which were originally designed to treat other conditions, however were discovered to reduce migraine attacks .

    Examples include:

    Preventatives
    The most commonly used migraine preventives include:
    ·       Beta Blockers
    ·       Anti-Epilepsy agents (Anti-Convulsants)

    PLEASE NOTE  Sodium Valproate (Epilim), should not be used in female children, in female adolescents, in women of childbearing potential and pregnant women, this is particularly important, given the significant teratogenic (increase risk of birth defects) potential of the medicine.  If you are taking Sodium Valproate (Epilim) please ensure your read the Patient Information Leaflet .
    ·       Calcium Channel Blockers
    ·       Tricyclic Anti-Depressants
    ·       5-HT Antagonists*

2.   Acute medication/Abortive 

Acute migraine medication attempts to relieve or stop the progression of an attack or to abort it once it has begun. Acute treatment should be taken as early as possible in the headache phase of an attack to prevent its escalation and to increase the drugs effectiveness

  • a.    Non Specific

    Simple analgesics are painkillers that often treat a headache attack effectively, such as Paracetamol, Ibuprofen or Aspirin.

    It is very important to speak with your pharmacist if you are buying Over The Counter Medication to manage headache. These medications have specific guidelines for taking them, and they come with side -effects and contra-indications.

    Over the counter medications can be dangerous .

    Over The Counter medications should form part of a treatment plan that has been made between you and your doctor.

  • b.    Migraine Specific

    Triptans are the migraine specific, prescription-only drugs that became available in Ireland in the 1990s. These drugs target specific groups of serotonin receptors in the brain that are known to be closely involved in migraine attacks.

    There are seven Triptan drugs available in Ireland and they are now considered to be the first line treatment of choice. They are:
    ·       Almotriptan
    ·       Frovatriptan
    ·       Sumatriptan
    ·       Eletriptan
    ·       Zolmitriptan
    ·       Naratriptan
    ·       Rizatriptan

    Studies have shown that treating the headache with triptans will resolve the pain within two hours in up to 80% of cases, but only if the drug is taken early when the pain is milder.

    Some people find that the headache will recur after taking a Triptan in which case a second dose can be taken. Some of the triptans are available in non-tablet form (e.g. nasal spray or dissolving tablet). These are quicker acting and may be useful for people who experience severe nausea.

    Triptans are licensed for people aged between 18 and 65, both those with and without aura. They are not suitable during pregnancy. They are also not suitable for people who have a history of any type of cardiovascular disease or high blood pressure.

c.  Special considerations regarding MOH risk 

What is Medication Overuse Headache (MOH)?

MOH is a chronic secondary headache which evolves because of frequent use of over the counter and prescription medication.
If you are taking medication on more than 6 days per month you should consult your GP. It affects as much as 5% of the population. (WHO 2023)

Who is at risk? 

People who live with migraine and/or other headache disorders such as migraine or tension type headache, are at risk of developing medication overuse headache. Some may not realise they live with migraine, so it is important to speak to your GP if you have any concerns about MOH.

The Symptoms 

Below are the most common symptoms associated with Medication.

Overuse Headache:

Worsening of frequency and/or severity of primary headache attacks (such as migraine attacks) over months/years  progressively increased use of acute medications (taken from IHS) .

  • Frequent headache with frequent use of painkillers.
  • Preventative medication becomes less effective
  • The headache is often at its worst in the morning and becomes more severe after physical activity
  • Headache temporarily worsens if medication is stopped/wears off
  • Other conditions such as depression or sleep disorders may also be present.
  • There may be nausea, forgetfulness, and/or restlessness

What To Do? 

Speak with your GP and Pharmacist if you are concerned that you are at risk of developing Medication Overuse Headache. Your GP will assess you and support you in preventing/treating Medication Overuse Headache.

3.   Non-Pharmacological  

Non Pharmacological treatment forms a core pillar of migraine treatment regimes.
​They include the means to manage migraine that are not medicines, and which support improved quality of life and positive patient outcomes .

a.    Mental health supports

Psychological support is an important form of support to people living with a headache condition. ​

Migraine and conditions such as anxiety and depression are understood to be reciprocal co morbidities.​This means that there is a more than co-incidental chance that the conditions are related, and that one can worsen the symptoms of the other – and vice versa.​Stress, anxiety, and depression are common migraine triggers and consequences.​

Psychological interventions that address mental health issues can help with migraine too and improve overall quality of life.

b.    Lifestyle

A number of lifestyle factors have been identified that can support a reduction in headache burden,  improved quality of life and support a person’s overall health​.

However: ​
It is always important to remember that living with a headache condition, means living with a complex illness and is not a person’s fault!!​It is important to remember that it is possible to become  stressed from making lifestyle changes​
or applying lifestyle recommendations in a way that reduces your quality of life can be even headache inducing !​

SEEDS for success

One useful example of lifestyle management is “SEEDS for success:”

S – Sleep​

Consistency is key: Aim to go to bed and wake up at the same time daily.​ Avoid oversleeping or sleep deprivation (where possible) both of which can trigger migraines.​ Wind down with a calming pre-sleep routine to promote quality rest.​
​

E – Eat

​
Aim for Regular meals and stay hydrated through the day. Understanding any triggers you may have that are food related can also help​
​

E – Exercise

Aim to build a regular routine of exercise into your lifestyle with the support of your doctor. ​
​

D – Diary

Helps identify patterns and supports discussions with your doctor​
​

S – Stress

Seeking support with stress such as counselling, can help develop coping techniques and can help to reduce migraine attack frequency and severity

HSE Guidelines on Exercise

Adults aged 18-64 years, aged 65+ including those living with a disability:​

At least 2 hours and 30 minutes to 5 hours of moderate-intensity aerobic physical activity; or at least 1 hour and 15 minutes to 2 hours and 30 minutes of vigorous-intensity aerobic physical activity throughout the week​

Additional muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups are recommended on 2 or more days a week​ as part of their weekly physical activity, older adults (aged 65+) and older adults living with a disability should do varied multicomponent physical activity that emphasises functional balance and strength training on 3 or more days a week, to enhance strength and capacity and to prevent falls.​

Limiting sedentary activity is also a key recommendation across all age groups.  Screen time is a very common type of sedentary activity, particularly screen time for young children and adolescents. Screen time includes time spent watching screen-based entertainment (TV, computer and mobile devices).

c.    Neuromodulation

Neuromodulation is a drug-free treatment that uses gentle electrical or magnetic pulses to change how the brain and nerves work. It’s used to help prevent migraine or stop migraine attacks when they start.​ It is used for both acute and preventive migraine treatment.

Devices:

Cefaly is an external trigeminal nerve stimulation (eTNS) unit. Similar to other neurostimulators for migraine treatment it targets the trigeminal nerve which is involved in migraine, A normal TENS device should not be used with Cefaly.

GammaCore Vagus Nerve Stimulator is a hand-held device that targets the Vagus nerve in the neck.

Other non-medicinal treatments

There are a number of non-medicinal lifestyle approaches that can be taken, usually as a migraine preventative.

These are:

Acupuncture

Acupuncture has been used for centuries in China to treat Headaches/Migraine with impressive results. More recently modern research has been building to prove it’s safety & efficacy, and in 2016 two Cochrane Reviews (high level research) were published showing that it can be a useful therapy for Tension Headaches and in reducing the frequency of Migraines.

Acupuncture is now seen as a sensible option to try and is now supported by organisations such as:

UK National Institute for Health & Care Excellence (NICE)

German Migraine & Headache/Neurology society.

American Migraine Foundation

Migraine association of Ireland.

This places acupuncture firmly in the ‘evidence based treatments’ now available for Migraine & Headache sufferers to try.
To find out more about the research see..
https://www.cochrane.org/CD001218/SYMPT_acupuncture-preventing-migraine-attacks
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007587.pub2/full

To find an acupuncturist see…

https://acupuncturecouncilofireland.com/member_list/
or…
https://afpa.ie/find-a-member/

Meditation

How Meditation Can Help with Migraine​
Medication can help to cope with and reduce stress, support improved sleep quality, help with mood regulation, and can support mental health and wellbeing​, which are all known migraine triggers.

Meditation also promotes relaxation & muscle release​ and helps to reduce muscle tension in the neck, shoulders, and scalp—areas often involved in migraine.

Yoga For Migraine

Yoga can help with migraine by reducing stress and tension—common migraine triggers—through controlled breathing, gentle movement, and relaxation techniques. Specifically, yoga has been shown to:​

Relax muscle tension, especially in the neck, shoulders, and upper back—areas often linked to migraine pain.​
Check out our talk here by Yoga expert Jane Whelan : The Benefits of Yoga for Migraine