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Dispelling Common Headache Myths
Patients may be familiar with several myths and have misconceptions about headaches and migraine, which often arise due to a combination of factors, including limited understanding of the conditions, cultural beliefs, misinformation, and the complex nature of headaches. Being aware of these myths and seeking accurate information help patients to better understand and manage their headaches.
Myth: Migraine Is the Most Common Type of Headache
This is not true. The most common type of headache is tension-type headache, and it's the kind of headache that almost everyone has from time to time. Between 40% and 80% of the US population have had some form of tension-type headache, but only about 13% of the adult population have migraine. Stress can make muscles in the head and neck tense and knotted, and these muscles can be the source of a tension-type headache. Sometimes these headaches are not at all related to muscles or stress. Neck position may also be a factor. Pain from this type of headache is usually felt on both sides of the head and presents more often as steady, dull pressure or pain that’s usually mild to moderate in intensity. The pain can be in the forehead and eyes or further back in the head. Tension-type headaches are not usually associated with nausea, vomiting, or light and sound sensitivity.
When a tension-type headache is really severe, patients could consider this headache a migraine. Clinicians can easily distinguish tension-type headache from migraine, which often presents on one side of the head, with moderate or severe intensity, is throbbing, and is associated with nausea, vomiting, and light and sound sensitivity.
Myth: Only Adults Get Headaches
False. Headaches aren’t experienced just by adults. However, unlike adults, children find it harder to explain their headaches. It is true that adults have more migraines than children; children’s migraines are often hard for doctors to recognize. A 6- to 9-year-old child is 50% less likely than an adult to have migraine, and their attacks are more often bilateral, are shorter, and respond to sleep quickly.
Myth: Migraines Are Just Really Bad Headaches
False. They are bad, but that is only a small part of the story. A migraine attack is different from other headaches; they actually are 1 of the 3 primary headache disorders, along with tension-type headache and cluster headache. A moderate or severe headache is one of the many characteristics of migraine, and some patients do not even have a headache during a migraine attack. Migraine is an inherited disease of the brain and other parts of the nervous system and can feel much worse than a normal headache. During a migraine attack, the brain does not process sensory data, such as lights, sound, or touch, properly. Patients might even experience visual, sensory, or speech problems (ie, auras) and sometime see flashing lights or zigzag lines that blink on and off or blind spots in their vision. Patients with migraine are often nauseated and severely bothered by light, sound, and even smells. Migraine headaches can last between 4 and 72 hours on average, causing disability, tiredness, and inability to think clearly or work productively, which adds to the burden of the disease. So, migraine is not just a headache.
Myth: More Women Than Men Experience Migraine
This is true. Epidemiologic data show a 3-fold higher incidence of migraine in women than men, starting from puberty and throughout life. From about 6 to 12 years, boys have a slightly higher incidence than girls, but then migraine occurrence levels off and becomes a disease primarily of women. The modulation of neuronal and vascular reactivity by hormones (namely estrogens and progesterone) is a crucial aspect of migraine in some women only. These hormones exert influence on a spectrum of neuromediators and neurotransmitters, potentially leading to functional and structural variations in specific brain regions associated with migraine pathogenesis. Beyond their central effects, sex hormones also modulate vascular tone. Therefore, migraine follows a pattern throughout a woman’s life corresponding to the fluctuation of estrogen. Within a year of their first menstrual period, many girls with migraine have their first attack. They are more likely to have a migraine attack just before and at the start of menses, and at other times of the month as well. They feel better when pregnant and worse after they stop breastfeeding, and they start to feel worse prior to menopause. Then they improve a few years after menopause.
While men are less at risk of having migraine, they’re more likely to have cluster headache than women (although this type of headache is rare compared with other headaches like migraine). Only about 0.1% or less of the population of adults in the US experience this type of headache. Cluster headache gets its name from the clustering of attacks occurring 2 to 6 times per day for 4 to 10 weeks and disappearing as quickly as they came. This headache pain is felt exclusively in or behind 1 eye and rarely elsewhere, on the same side of the head. There is also a clustering of other symptoms called autonomic findings, such as tearing and redness of 1 eye, stuffiness and running in 1 nostril, sweating over 1 eyebrow, drooping of 1 eyelid, and a small pupil—all on the same side of the head the pain is radiating from. Most patients have only some of these findings. Cluster headaches tend to occur every year around the same time (circannual). When a patient is in a cycle of cluster headaches, they often occur at the same time each day (circadian). These set times of the year and of the day are caused by the biological clock deep down under the brain in the hypothalamus.
Myth: All Headaches Are Psychological
This is not true. Usually the underlying cause of migraine is genetically-inherited, but each attack may be triggered by an underlying cause (eg, drop in barometric pressure, menses, certain food/drinks, lack of sleep, stress, etc). Even tension-type headaches can be triggered by muscles in the head and neck becoming tense, stressful events, or jaw issues, which in turn send out pain signals that are felt on both sides of the head.
Many years ago (ie, 1950s-1960s), it was thought that the underlying cause of migraine in women was psychological issues; that has been disproven many times. Both men and women have migraine, and they both can have coexisting psychological issues (ie, depression, anxiety, and other psychiatric problems).
Myth: Migraines Aren’t Serious
Most types of migraine in and of themselves are not serious; however, chronic migraine can continue for years and is debilitating and disabling—becoming a serious issue for patients. These patients usually take many medications, are obese, can have big changes in weight and severe insomnia, don’t exercise enough, and develop other illnesses. Migraine can severely impact quality of life; many people living with migraine have reported reduced productivity while at work, lack of promotion, loss of jobs, and a disruption in their family, social, and leisure activities.
Migraine attacks vary from one person to another and can be quite different from one attack to another in the same person. Hemiplegic migraine, a rare and distinct subtype that is sometimes inherited, is characterized by neurologic symptoms (multiple auras, including a significant weakness or paralysis on 1 side of the body). Although these patients seem much sicker and have multiple types of auras and 1-sided weakness with a prolonged headache, most recover without serious consequences.
Myth: Lack of Sleep Causes Migraine
Yes, lack of sleep is a known trigger for migraine in many people, but lack of sleep is not the cause of migraine. Sleep deprivation and irregular sleep patterns can disrupt the delicate balance of neurotransmitters and hormones in the brain, potentially triggering migraine in susceptible individuals. Additionally, inadequate sleep may contribute to increased stress and tension, which are also common triggers for migraine. In fact, many people with migraine do have sleep issues, which can range from trouble falling asleep to early morning awakening without being able to get back to sleep or frequently interrupted sleep each night. Correcting the sleep problem is part of the migraine therapy. Patients should be checked for sleep apnea if they wake with headache in the morning. Medication overuse headache should also be considered.
Establishing a regular sleep routine and ensuring an adequate amount of sleep can be important components of managing migraine symptoms, particularly for those who find a connection between their sleep patterns and the onset of a migraine attack. However, the relationship between sleep and migraine can vary widely among individuals, and other factors may also contribute to migraine triggers.
Myth: Caffeine Causes Migraine
This is a myth; caffeine does not cause migraine but definitely can be a trigger for some people. Coffee and caffeine and migraine have a complex relationship: excessive caffeine consumption or withdrawal can trigger migraine attacks, but caffeine can also help alleviate headaches (including migraine) due to its analgesic properties. Caffeine is a major component of many over-the-counter medicines for migraine. Some people find drinking coffee or a soda or taking a caffeine tablet at the onset of a migraine attack lowers the intensity of a migraine headache. Regular use of caffeine, either as “treatment” or for pleasure, is not advised in patients with migraine. Most doctors limit caffeine to a regular cup of coffee or tea per day, with no caffeine-containing sodas or chocolate in their patients with migraine; caffeine withdrawal is also a frequent migraine trigger. Patients can notice withdrawal headaches when they stop coffee, even if they are only consuming 1 cup per day. Most people drink a lot more.
Myth: Headache Medicine Will Cure Migraine
False. There currently is no “cure” for migraine. There are several medicines available that certainly can help prevent, abort, or control symptoms of migraine. Some of these medications include over-the-counter analgesics; triptans (like sumatriptan or rizatriptan); gepants, which are small molecule CGRP (calcitonin gene-related peptide) antagonists; CGRP antibodies given by injection; antidepressants; antiseizure medicines; and beta-blockers.
Myth: You Cannot Take Any Migraine Medications During Pregnancy
Migraine medications, such as triptans, are relatively safe during pregnancy, particularly after the first trimester. Acetaminophen in low doses is safe as well, but some of the preventive antiseizure medications should be avoided due to the risk of halting the pregnancy or producing a congenital malformation. Noninvasive wearable devices (such as Nerivio), biofeedback training, mindfulness, and relaxation techniques are particularly appealing to pregnant women as they have high efficacy with virtually no lasting side effects.
Although patients who are pregnant might have an increased flurry of migraine headaches in the first trimester of their pregnancy, they will most likely have a decreased number of attacks in the next 2 trimesters of their pregnancy, making them feel really well. The first trimester is a dangerous time for fetuses to be exposed to certain medicines that are foreign to them, as their organs are still being formed. There are medicines that doctors feel are less problematic both for acute care and prevention of migraine during pregnancy; therefore, patients with a history of migraine should always consult with their obstetrician-gynecologist and a neurologist (or other doctor they usually see for their migraine care) before taking any medication if they are planning a pregnancy or are pregnant.
Effective nonpharmaceutical options are available for all patients with migraine, whether pregnant or not. Maintaining a healthy lifestyle, which includes getting 7 to 10 hours of sleep each night, drinking plenty of water each day, getting ample nutrition from healthy foods, and eliminating as many sources of extra stress as possible can help reduce the risk of a migraine, even when exposed to a known trigger.
Medications may also lead to headaches by a phenomenon called medication overuse headache, if the rescue medication is taken too often. Clinicians recommend no more than 2 days per week of any acute care medication and taking a good preventive medication if needed.
Myth: “Migraine Diets” Cure Migraine
This is false. Avoiding known food triggers can reduce the risk of a migraine attack, but a diet regimen is not a cure. Although eating healthy foods and avoiding certain kinds of food that trigger migraine can eliminate triggering the episodes, there are other factors to take into account. For instance, the migraine diet cannot address a lack of sleep, stress, or hormonal changes a person experiences. Only very few patients with migraine can say their medication has cured their migraine, but it could happen.
Myth: Dietary Supplements Can Cure Migraine
This myth is not true. Supplements can help migraine headache or prevent triggering it, but they won’t cure it. Supplements, such as magnesium, vitamin D3, coenzyme Q10, vitamin B2 (riboflavin), feverfew, melatonin, and vitamin B2 are important additions to the migraine treatment armamentarium, but no one specific vitamin/mineral or supplement has been proven to help prevent or relieve migraine for everyone. They help some people immensely and do little for others, just as with any pharmacologic agent.
Myth: It’s Not a Migraine Unless You Experience Aura
This is not true, as most migraines present without aura. Migraine with typical aura affects 30% of patients with migraine.
Myth: Researchers No Longer Investigate Migraine
False; there are several ongoing studies working to address the pathophysiology of migraine and find new treatment options. Recently, neuromodulation devices have entered the market. One such device from Theranica (called Nerivio) now has clearance from the US Food and Drug Administration for acute and preventive migraine treatment from age 12 and up. One phase 4 study by Theranica shows that Nerivio appears to be safe during pregnancy.
Several migraine studies of note include the following:
OnabotulinumtoxinA as a treatment for hemiplegic migraine: This project aims to evaluate the response to onabotulinumtoxinA treatments in patients with hemiplegic migraine evaluated at Mayo Clinic.
Occipital nerve stimulation for migraine: OPTIMISE. This study is evaluating the safety and efficacy of occipital nerve stimulation (ONS) using the Boston Scientific Corporation (BSC) Precision™ System in the management of intractable chronic migraine, when used in conjunction with antimigraine medications.
The Medication Overuse Treatment Strategy trial: This study is comparing the outcomes among patients randomized to 1 of the 2 treatment strategies for treating patients who have chronic migraine with medication overuse.
Metformin is being investigated as a treatment for the prevention of episodic migraine.
Myth: Migraine Cannot Be Diagnosed Without an Imaging Exam
This is false. Migraine is a clinical diagnosis and does not need any imaging to confirm. Imaging is indicated only if the symptoms are not clear or if there are neurologic symptoms or warning signs accompanying the migraine. In such cases, imaging would be warranted to rule out other pathologies. A magnetic resonance imaging scan is performed to rule out other pathology, not to diagnose migraine. A clinician must identify a pattern in the patient’s history according to the diagnostic criteria of the International Headache Society to diagnose migraine, which include that the patient had 5 previous attacks without aura or 2 attacks with aura.
Summary
Headaches, especially migraine, can be unpleasant and disabling and can significantly affect a patient’s quality of life. However, pharmaceutical and nonpharmaceutical interventions that can help are available. Lifestyle changes, including diet, sleep, and stress reduction can ease symptoms and reduce the frequency of migraine attacks. As researchers continue to investigate the pathophysiology of migraine, they are sure to identify better treatments and, perhaps one day—a cure.
Patients may be familiar with several myths and have misconceptions about headaches and migraine, which often arise due to a combination of factors, including limited understanding of the conditions, cultural beliefs, misinformation, and the complex nature of headaches. Being aware of these myths and seeking accurate information help patients to better understand and manage their headaches.
Myth: Migraine Is the Most Common Type of Headache
This is not true. The most common type of headache is tension-type headache, and it's the kind of headache that almost everyone has from time to time. Between 40% and 80% of the US population have had some form of tension-type headache, but only about 13% of the adult population have migraine. Stress can make muscles in the head and neck tense and knotted, and these muscles can be the source of a tension-type headache. Sometimes these headaches are not at all related to muscles or stress. Neck position may also be a factor. Pain from this type of headache is usually felt on both sides of the head and presents more often as steady, dull pressure or pain that’s usually mild to moderate in intensity. The pain can be in the forehead and eyes or further back in the head. Tension-type headaches are not usually associated with nausea, vomiting, or light and sound sensitivity.
When a tension-type headache is really severe, patients could consider this headache a migraine. Clinicians can easily distinguish tension-type headache from migraine, which often presents on one side of the head, with moderate or severe intensity, is throbbing, and is associated with nausea, vomiting, and light and sound sensitivity.
Myth: Only Adults Get Headaches
False. Headaches aren’t experienced just by adults. However, unlike adults, children find it harder to explain their headaches. It is true that adults have more migraines than children; children’s migraines are often hard for doctors to recognize. A 6- to 9-year-old child is 50% less likely than an adult to have migraine, and their attacks are more often bilateral, are shorter, and respond to sleep quickly.
Myth: Migraines Are Just Really Bad Headaches
False. They are bad, but that is only a small part of the story. A migraine attack is different from other headaches; they actually are 1 of the 3 primary headache disorders, along with tension-type headache and cluster headache. A moderate or severe headache is one of the many characteristics of migraine, and some patients do not even have a headache during a migraine attack. Migraine is an inherited disease of the brain and other parts of the nervous system and can feel much worse than a normal headache. During a migraine attack, the brain does not process sensory data, such as lights, sound, or touch, properly. Patients might even experience visual, sensory, or speech problems (ie, auras) and sometime see flashing lights or zigzag lines that blink on and off or blind spots in their vision. Patients with migraine are often nauseated and severely bothered by light, sound, and even smells. Migraine headaches can last between 4 and 72 hours on average, causing disability, tiredness, and inability to think clearly or work productively, which adds to the burden of the disease. So, migraine is not just a headache.
Myth: More Women Than Men Experience Migraine
This is true. Epidemiologic data show a 3-fold higher incidence of migraine in women than men, starting from puberty and throughout life. From about 6 to 12 years, boys have a slightly higher incidence than girls, but then migraine occurrence levels off and becomes a disease primarily of women. The modulation of neuronal and vascular reactivity by hormones (namely estrogens and progesterone) is a crucial aspect of migraine in some women only. These hormones exert influence on a spectrum of neuromediators and neurotransmitters, potentially leading to functional and structural variations in specific brain regions associated with migraine pathogenesis. Beyond their central effects, sex hormones also modulate vascular tone. Therefore, migraine follows a pattern throughout a woman’s life corresponding to the fluctuation of estrogen. Within a year of their first menstrual period, many girls with migraine have their first attack. They are more likely to have a migraine attack just before and at the start of menses, and at other times of the month as well. They feel better when pregnant and worse after they stop breastfeeding, and they start to feel worse prior to menopause. Then they improve a few years after menopause.
While men are less at risk of having migraine, they’re more likely to have cluster headache than women (although this type of headache is rare compared with other headaches like migraine). Only about 0.1% or less of the population of adults in the US experience this type of headache. Cluster headache gets its name from the clustering of attacks occurring 2 to 6 times per day for 4 to 10 weeks and disappearing as quickly as they came. This headache pain is felt exclusively in or behind 1 eye and rarely elsewhere, on the same side of the head. There is also a clustering of other symptoms called autonomic findings, such as tearing and redness of 1 eye, stuffiness and running in 1 nostril, sweating over 1 eyebrow, drooping of 1 eyelid, and a small pupil—all on the same side of the head the pain is radiating from. Most patients have only some of these findings. Cluster headaches tend to occur every year around the same time (circannual). When a patient is in a cycle of cluster headaches, they often occur at the same time each day (circadian). These set times of the year and of the day are caused by the biological clock deep down under the brain in the hypothalamus.
Myth: All Headaches Are Psychological
This is not true. Usually the underlying cause of migraine is genetically-inherited, but each attack may be triggered by an underlying cause (eg, drop in barometric pressure, menses, certain food/drinks, lack of sleep, stress, etc). Even tension-type headaches can be triggered by muscles in the head and neck becoming tense, stressful events, or jaw issues, which in turn send out pain signals that are felt on both sides of the head.
Many years ago (ie, 1950s-1960s), it was thought that the underlying cause of migraine in women was psychological issues; that has been disproven many times. Both men and women have migraine, and they both can have coexisting psychological issues (ie, depression, anxiety, and other psychiatric problems).
Myth: Migraines Aren’t Serious
Most types of migraine in and of themselves are not serious; however, chronic migraine can continue for years and is debilitating and disabling—becoming a serious issue for patients. These patients usually take many medications, are obese, can have big changes in weight and severe insomnia, don’t exercise enough, and develop other illnesses. Migraine can severely impact quality of life; many people living with migraine have reported reduced productivity while at work, lack of promotion, loss of jobs, and a disruption in their family, social, and leisure activities.
Migraine attacks vary from one person to another and can be quite different from one attack to another in the same person. Hemiplegic migraine, a rare and distinct subtype that is sometimes inherited, is characterized by neurologic symptoms (multiple auras, including a significant weakness or paralysis on 1 side of the body). Although these patients seem much sicker and have multiple types of auras and 1-sided weakness with a prolonged headache, most recover without serious consequences.
Myth: Lack of Sleep Causes Migraine
Yes, lack of sleep is a known trigger for migraine in many people, but lack of sleep is not the cause of migraine. Sleep deprivation and irregular sleep patterns can disrupt the delicate balance of neurotransmitters and hormones in the brain, potentially triggering migraine in susceptible individuals. Additionally, inadequate sleep may contribute to increased stress and tension, which are also common triggers for migraine. In fact, many people with migraine do have sleep issues, which can range from trouble falling asleep to early morning awakening without being able to get back to sleep or frequently interrupted sleep each night. Correcting the sleep problem is part of the migraine therapy. Patients should be checked for sleep apnea if they wake with headache in the morning. Medication overuse headache should also be considered.
Establishing a regular sleep routine and ensuring an adequate amount of sleep can be important components of managing migraine symptoms, particularly for those who find a connection between their sleep patterns and the onset of a migraine attack. However, the relationship between sleep and migraine can vary widely among individuals, and other factors may also contribute to migraine triggers.
Myth: Caffeine Causes Migraine
This is a myth; caffeine does not cause migraine but definitely can be a trigger for some people. Coffee and caffeine and migraine have a complex relationship: excessive caffeine consumption or withdrawal can trigger migraine attacks, but caffeine can also help alleviate headaches (including migraine) due to its analgesic properties. Caffeine is a major component of many over-the-counter medicines for migraine. Some people find drinking coffee or a soda or taking a caffeine tablet at the onset of a migraine attack lowers the intensity of a migraine headache. Regular use of caffeine, either as “treatment” or for pleasure, is not advised in patients with migraine. Most doctors limit caffeine to a regular cup of coffee or tea per day, with no caffeine-containing sodas or chocolate in their patients with migraine; caffeine withdrawal is also a frequent migraine trigger. Patients can notice withdrawal headaches when they stop coffee, even if they are only consuming 1 cup per day. Most people drink a lot more.
Myth: Headache Medicine Will Cure Migraine
False. There currently is no “cure” for migraine. There are several medicines available that certainly can help prevent, abort, or control symptoms of migraine. Some of these medications include over-the-counter analgesics; triptans (like sumatriptan or rizatriptan); gepants, which are small molecule CGRP (calcitonin gene-related peptide) antagonists; CGRP antibodies given by injection; antidepressants; antiseizure medicines; and beta-blockers.
Myth: You Cannot Take Any Migraine Medications During Pregnancy
Migraine medications, such as triptans, are relatively safe during pregnancy, particularly after the first trimester. Acetaminophen in low doses is safe as well, but some of the preventive antiseizure medications should be avoided due to the risk of halting the pregnancy or producing a congenital malformation. Noninvasive wearable devices (such as Nerivio), biofeedback training, mindfulness, and relaxation techniques are particularly appealing to pregnant women as they have high efficacy with virtually no lasting side effects.
Although patients who are pregnant might have an increased flurry of migraine headaches in the first trimester of their pregnancy, they will most likely have a decreased number of attacks in the next 2 trimesters of their pregnancy, making them feel really well. The first trimester is a dangerous time for fetuses to be exposed to certain medicines that are foreign to them, as their organs are still being formed. There are medicines that doctors feel are less problematic both for acute care and prevention of migraine during pregnancy; therefore, patients with a history of migraine should always consult with their obstetrician-gynecologist and a neurologist (or other doctor they usually see for their migraine care) before taking any medication if they are planning a pregnancy or are pregnant.
Effective nonpharmaceutical options are available for all patients with migraine, whether pregnant or not. Maintaining a healthy lifestyle, which includes getting 7 to 10 hours of sleep each night, drinking plenty of water each day, getting ample nutrition from healthy foods, and eliminating as many sources of extra stress as possible can help reduce the risk of a migraine, even when exposed to a known trigger.
Medications may also lead to headaches by a phenomenon called medication overuse headache, if the rescue medication is taken too often. Clinicians recommend no more than 2 days per week of any acute care medication and taking a good preventive medication if needed.
Myth: “Migraine Diets” Cure Migraine
This is false. Avoiding known food triggers can reduce the risk of a migraine attack, but a diet regimen is not a cure. Although eating healthy foods and avoiding certain kinds of food that trigger migraine can eliminate triggering the episodes, there are other factors to take into account. For instance, the migraine diet cannot address a lack of sleep, stress, or hormonal changes a person experiences. Only very few patients with migraine can say their medication has cured their migraine, but it could happen.
Myth: Dietary Supplements Can Cure Migraine
This myth is not true. Supplements can help migraine headache or prevent triggering it, but they won’t cure it. Supplements, such as magnesium, vitamin D3, coenzyme Q10, vitamin B2 (riboflavin), feverfew, melatonin, and vitamin B2 are important additions to the migraine treatment armamentarium, but no one specific vitamin/mineral or supplement has been proven to help prevent or relieve migraine for everyone. They help some people immensely and do little for others, just as with any pharmacologic agent.
Myth: It’s Not a Migraine Unless You Experience Aura
This is not true, as most migraines present without aura. Migraine with typical aura affects 30% of patients with migraine.
Myth: Researchers No Longer Investigate Migraine
False; there are several ongoing studies working to address the pathophysiology of migraine and find new treatment options. Recently, neuromodulation devices have entered the market. One such device from Theranica (called Nerivio) now has clearance from the US Food and Drug Administration for acute and preventive migraine treatment from age 12 and up. One phase 4 study by Theranica shows that Nerivio appears to be safe during pregnancy.
Several migraine studies of note include the following:
OnabotulinumtoxinA as a treatment for hemiplegic migraine: This project aims to evaluate the response to onabotulinumtoxinA treatments in patients with hemiplegic migraine evaluated at Mayo Clinic.
Occipital nerve stimulation for migraine: OPTIMISE. This study is evaluating the safety and efficacy of occipital nerve stimulation (ONS) using the Boston Scientific Corporation (BSC) Precision™ System in the management of intractable chronic migraine, when used in conjunction with antimigraine medications.
The Medication Overuse Treatment Strategy trial: This study is comparing the outcomes among patients randomized to 1 of the 2 treatment strategies for treating patients who have chronic migraine with medication overuse.
Metformin is being investigated as a treatment for the prevention of episodic migraine.
Myth: Migraine Cannot Be Diagnosed Without an Imaging Exam
This is false. Migraine is a clinical diagnosis and does not need any imaging to confirm. Imaging is indicated only if the symptoms are not clear or if there are neurologic symptoms or warning signs accompanying the migraine. In such cases, imaging would be warranted to rule out other pathologies. A magnetic resonance imaging scan is performed to rule out other pathology, not to diagnose migraine. A clinician must identify a pattern in the patient’s history according to the diagnostic criteria of the International Headache Society to diagnose migraine, which include that the patient had 5 previous attacks without aura or 2 attacks with aura.
Summary
Headaches, especially migraine, can be unpleasant and disabling and can significantly affect a patient’s quality of life. However, pharmaceutical and nonpharmaceutical interventions that can help are available. Lifestyle changes, including diet, sleep, and stress reduction can ease symptoms and reduce the frequency of migraine attacks. As researchers continue to investigate the pathophysiology of migraine, they are sure to identify better treatments and, perhaps one day—a cure.
Patients may be familiar with several myths and have misconceptions about headaches and migraine, which often arise due to a combination of factors, including limited understanding of the conditions, cultural beliefs, misinformation, and the complex nature of headaches. Being aware of these myths and seeking accurate information help patients to better understand and manage their headaches.
Myth: Migraine Is the Most Common Type of Headache
This is not true. The most common type of headache is tension-type headache, and it's the kind of headache that almost everyone has from time to time. Between 40% and 80% of the US population have had some form of tension-type headache, but only about 13% of the adult population have migraine. Stress can make muscles in the head and neck tense and knotted, and these muscles can be the source of a tension-type headache. Sometimes these headaches are not at all related to muscles or stress. Neck position may also be a factor. Pain from this type of headache is usually felt on both sides of the head and presents more often as steady, dull pressure or pain that’s usually mild to moderate in intensity. The pain can be in the forehead and eyes or further back in the head. Tension-type headaches are not usually associated with nausea, vomiting, or light and sound sensitivity.
When a tension-type headache is really severe, patients could consider this headache a migraine. Clinicians can easily distinguish tension-type headache from migraine, which often presents on one side of the head, with moderate or severe intensity, is throbbing, and is associated with nausea, vomiting, and light and sound sensitivity.
Myth: Only Adults Get Headaches
False. Headaches aren’t experienced just by adults. However, unlike adults, children find it harder to explain their headaches. It is true that adults have more migraines than children; children’s migraines are often hard for doctors to recognize. A 6- to 9-year-old child is 50% less likely than an adult to have migraine, and their attacks are more often bilateral, are shorter, and respond to sleep quickly.
Myth: Migraines Are Just Really Bad Headaches
False. They are bad, but that is only a small part of the story. A migraine attack is different from other headaches; they actually are 1 of the 3 primary headache disorders, along with tension-type headache and cluster headache. A moderate or severe headache is one of the many characteristics of migraine, and some patients do not even have a headache during a migraine attack. Migraine is an inherited disease of the brain and other parts of the nervous system and can feel much worse than a normal headache. During a migraine attack, the brain does not process sensory data, such as lights, sound, or touch, properly. Patients might even experience visual, sensory, or speech problems (ie, auras) and sometime see flashing lights or zigzag lines that blink on and off or blind spots in their vision. Patients with migraine are often nauseated and severely bothered by light, sound, and even smells. Migraine headaches can last between 4 and 72 hours on average, causing disability, tiredness, and inability to think clearly or work productively, which adds to the burden of the disease. So, migraine is not just a headache.
Myth: More Women Than Men Experience Migraine
This is true. Epidemiologic data show a 3-fold higher incidence of migraine in women than men, starting from puberty and throughout life. From about 6 to 12 years, boys have a slightly higher incidence than girls, but then migraine occurrence levels off and becomes a disease primarily of women. The modulation of neuronal and vascular reactivity by hormones (namely estrogens and progesterone) is a crucial aspect of migraine in some women only. These hormones exert influence on a spectrum of neuromediators and neurotransmitters, potentially leading to functional and structural variations in specific brain regions associated with migraine pathogenesis. Beyond their central effects, sex hormones also modulate vascular tone. Therefore, migraine follows a pattern throughout a woman’s life corresponding to the fluctuation of estrogen. Within a year of their first menstrual period, many girls with migraine have their first attack. They are more likely to have a migraine attack just before and at the start of menses, and at other times of the month as well. They feel better when pregnant and worse after they stop breastfeeding, and they start to feel worse prior to menopause. Then they improve a few years after menopause.
While men are less at risk of having migraine, they’re more likely to have cluster headache than women (although this type of headache is rare compared with other headaches like migraine). Only about 0.1% or less of the population of adults in the US experience this type of headache. Cluster headache gets its name from the clustering of attacks occurring 2 to 6 times per day for 4 to 10 weeks and disappearing as quickly as they came. This headache pain is felt exclusively in or behind 1 eye and rarely elsewhere, on the same side of the head. There is also a clustering of other symptoms called autonomic findings, such as tearing and redness of 1 eye, stuffiness and running in 1 nostril, sweating over 1 eyebrow, drooping of 1 eyelid, and a small pupil—all on the same side of the head the pain is radiating from. Most patients have only some of these findings. Cluster headaches tend to occur every year around the same time (circannual). When a patient is in a cycle of cluster headaches, they often occur at the same time each day (circadian). These set times of the year and of the day are caused by the biological clock deep down under the brain in the hypothalamus.
Myth: All Headaches Are Psychological
This is not true. Usually the underlying cause of migraine is genetically-inherited, but each attack may be triggered by an underlying cause (eg, drop in barometric pressure, menses, certain food/drinks, lack of sleep, stress, etc). Even tension-type headaches can be triggered by muscles in the head and neck becoming tense, stressful events, or jaw issues, which in turn send out pain signals that are felt on both sides of the head.
Many years ago (ie, 1950s-1960s), it was thought that the underlying cause of migraine in women was psychological issues; that has been disproven many times. Both men and women have migraine, and they both can have coexisting psychological issues (ie, depression, anxiety, and other psychiatric problems).
Myth: Migraines Aren’t Serious
Most types of migraine in and of themselves are not serious; however, chronic migraine can continue for years and is debilitating and disabling—becoming a serious issue for patients. These patients usually take many medications, are obese, can have big changes in weight and severe insomnia, don’t exercise enough, and develop other illnesses. Migraine can severely impact quality of life; many people living with migraine have reported reduced productivity while at work, lack of promotion, loss of jobs, and a disruption in their family, social, and leisure activities.
Migraine attacks vary from one person to another and can be quite different from one attack to another in the same person. Hemiplegic migraine, a rare and distinct subtype that is sometimes inherited, is characterized by neurologic symptoms (multiple auras, including a significant weakness or paralysis on 1 side of the body). Although these patients seem much sicker and have multiple types of auras and 1-sided weakness with a prolonged headache, most recover without serious consequences.
Myth: Lack of Sleep Causes Migraine
Yes, lack of sleep is a known trigger for migraine in many people, but lack of sleep is not the cause of migraine. Sleep deprivation and irregular sleep patterns can disrupt the delicate balance of neurotransmitters and hormones in the brain, potentially triggering migraine in susceptible individuals. Additionally, inadequate sleep may contribute to increased stress and tension, which are also common triggers for migraine. In fact, many people with migraine do have sleep issues, which can range from trouble falling asleep to early morning awakening without being able to get back to sleep or frequently interrupted sleep each night. Correcting the sleep problem is part of the migraine therapy. Patients should be checked for sleep apnea if they wake with headache in the morning. Medication overuse headache should also be considered.
Establishing a regular sleep routine and ensuring an adequate amount of sleep can be important components of managing migraine symptoms, particularly for those who find a connection between their sleep patterns and the onset of a migraine attack. However, the relationship between sleep and migraine can vary widely among individuals, and other factors may also contribute to migraine triggers.
Myth: Caffeine Causes Migraine
This is a myth; caffeine does not cause migraine but definitely can be a trigger for some people. Coffee and caffeine and migraine have a complex relationship: excessive caffeine consumption or withdrawal can trigger migraine attacks, but caffeine can also help alleviate headaches (including migraine) due to its analgesic properties. Caffeine is a major component of many over-the-counter medicines for migraine. Some people find drinking coffee or a soda or taking a caffeine tablet at the onset of a migraine attack lowers the intensity of a migraine headache. Regular use of caffeine, either as “treatment” or for pleasure, is not advised in patients with migraine. Most doctors limit caffeine to a regular cup of coffee or tea per day, with no caffeine-containing sodas or chocolate in their patients with migraine; caffeine withdrawal is also a frequent migraine trigger. Patients can notice withdrawal headaches when they stop coffee, even if they are only consuming 1 cup per day. Most people drink a lot more.
Myth: Headache Medicine Will Cure Migraine
False. There currently is no “cure” for migraine. There are several medicines available that certainly can help prevent, abort, or control symptoms of migraine. Some of these medications include over-the-counter analgesics; triptans (like sumatriptan or rizatriptan); gepants, which are small molecule CGRP (calcitonin gene-related peptide) antagonists; CGRP antibodies given by injection; antidepressants; antiseizure medicines; and beta-blockers.
Myth: You Cannot Take Any Migraine Medications During Pregnancy
Migraine medications, such as triptans, are relatively safe during pregnancy, particularly after the first trimester. Acetaminophen in low doses is safe as well, but some of the preventive antiseizure medications should be avoided due to the risk of halting the pregnancy or producing a congenital malformation. Noninvasive wearable devices (such as Nerivio), biofeedback training, mindfulness, and relaxation techniques are particularly appealing to pregnant women as they have high efficacy with virtually no lasting side effects.
Although patients who are pregnant might have an increased flurry of migraine headaches in the first trimester of their pregnancy, they will most likely have a decreased number of attacks in the next 2 trimesters of their pregnancy, making them feel really well. The first trimester is a dangerous time for fetuses to be exposed to certain medicines that are foreign to them, as their organs are still being formed. There are medicines that doctors feel are less problematic both for acute care and prevention of migraine during pregnancy; therefore, patients with a history of migraine should always consult with their obstetrician-gynecologist and a neurologist (or other doctor they usually see for their migraine care) before taking any medication if they are planning a pregnancy or are pregnant.
Effective nonpharmaceutical options are available for all patients with migraine, whether pregnant or not. Maintaining a healthy lifestyle, which includes getting 7 to 10 hours of sleep each night, drinking plenty of water each day, getting ample nutrition from healthy foods, and eliminating as many sources of extra stress as possible can help reduce the risk of a migraine, even when exposed to a known trigger.
Medications may also lead to headaches by a phenomenon called medication overuse headache, if the rescue medication is taken too often. Clinicians recommend no more than 2 days per week of any acute care medication and taking a good preventive medication if needed.
Myth: “Migraine Diets” Cure Migraine
This is false. Avoiding known food triggers can reduce the risk of a migraine attack, but a diet regimen is not a cure. Although eating healthy foods and avoiding certain kinds of food that trigger migraine can eliminate triggering the episodes, there are other factors to take into account. For instance, the migraine diet cannot address a lack of sleep, stress, or hormonal changes a person experiences. Only very few patients with migraine can say their medication has cured their migraine, but it could happen.
Myth: Dietary Supplements Can Cure Migraine
This myth is not true. Supplements can help migraine headache or prevent triggering it, but they won’t cure it. Supplements, such as magnesium, vitamin D3, coenzyme Q10, vitamin B2 (riboflavin), feverfew, melatonin, and vitamin B2 are important additions to the migraine treatment armamentarium, but no one specific vitamin/mineral or supplement has been proven to help prevent or relieve migraine for everyone. They help some people immensely and do little for others, just as with any pharmacologic agent.
Myth: It’s Not a Migraine Unless You Experience Aura
This is not true, as most migraines present without aura. Migraine with typical aura affects 30% of patients with migraine.
Myth: Researchers No Longer Investigate Migraine
False; there are several ongoing studies working to address the pathophysiology of migraine and find new treatment options. Recently, neuromodulation devices have entered the market. One such device from Theranica (called Nerivio) now has clearance from the US Food and Drug Administration for acute and preventive migraine treatment from age 12 and up. One phase 4 study by Theranica shows that Nerivio appears to be safe during pregnancy.
Several migraine studies of note include the following:
OnabotulinumtoxinA as a treatment for hemiplegic migraine: This project aims to evaluate the response to onabotulinumtoxinA treatments in patients with hemiplegic migraine evaluated at Mayo Clinic.
Occipital nerve stimulation for migraine: OPTIMISE. This study is evaluating the safety and efficacy of occipital nerve stimulation (ONS) using the Boston Scientific Corporation (BSC) Precision™ System in the management of intractable chronic migraine, when used in conjunction with antimigraine medications.
The Medication Overuse Treatment Strategy trial: This study is comparing the outcomes among patients randomized to 1 of the 2 treatment strategies for treating patients who have chronic migraine with medication overuse.
Metformin is being investigated as a treatment for the prevention of episodic migraine.
Myth: Migraine Cannot Be Diagnosed Without an Imaging Exam
This is false. Migraine is a clinical diagnosis and does not need any imaging to confirm. Imaging is indicated only if the symptoms are not clear or if there are neurologic symptoms or warning signs accompanying the migraine. In such cases, imaging would be warranted to rule out other pathologies. A magnetic resonance imaging scan is performed to rule out other pathology, not to diagnose migraine. A clinician must identify a pattern in the patient’s history according to the diagnostic criteria of the International Headache Society to diagnose migraine, which include that the patient had 5 previous attacks without aura or 2 attacks with aura.
Summary
Headaches, especially migraine, can be unpleasant and disabling and can significantly affect a patient’s quality of life. However, pharmaceutical and nonpharmaceutical interventions that can help are available. Lifestyle changes, including diet, sleep, and stress reduction can ease symptoms and reduce the frequency of migraine attacks. As researchers continue to investigate the pathophysiology of migraine, they are sure to identify better treatments and, perhaps one day—a cure.
The Evolution of Acute Care Medications for Migraine Treatment: A Conversation With a 51-Year Headache Specialist
MDedge: What were the earliest acute care medications available for migraine?
Dr. Rapoport: In the 1940s, ergotamine tartrate tablets and sublingual tablets were introduced as therapy to treat migraine. They were not that well absorbed, caused nausea, and were not very effective—but they were the only treatment option. Then, beginning in the early 1990s, doctors began prescribing a class of medications called triptans to stop a migraine in progress. Patients are instructed to quickly take the triptan as soon as they know it is or will be a migraine headache; if they wait too long, it may not work as well—or at all. If they don’t have any improvement in 2 hours, they are encouraged to repeat the dosage, even though it often does not work well.
As I strongly recommend to my patients, triptans should not be used more than 2 days per week. An average of 3 days per week or more is too much, and triptan medications can cause medication overuse headache (MOH). If the patient develops MOH, they usually have more headaches rather than fewer—and the medication stops working well.
These medicines work in about 60% of patients and not so well in the other 40%. They do cause side effects in certain people, which may include some pain in their chest or neck muscles and constriction of blood vessels. Some patients also feel a warm-to-hot feeling all over, tingling sensation, drowsiness, dizziness, and other side effects. Some will experience these side effects but continue to take these medications because they work; however, some patients can’t take them because they find the side effects to be too bothersome.
The first triptan to be marketed (in 1992) was a 6-mg, self-injected, subcutaneous injection of sumatriptan (Imitrex). Injection was the only available delivery method for a triptan until 1994, when the tablet form became available.
Typically, patients who hadn’t taken the sumatriptan injections preferred to start with the tablets, but the patients who had been taking the injection form were used to it and preferred to keep taking it. They knew that it worked well, and if they had mild side effects, they weren’t troubled by them. However, most new patients, when given a choice, asked for the tablet instead of the injection. In 1996, sumatriptan nasal spray was introduced, which is inconsistently absorbed, and patients report it does not taste or smell good.
Within a few years, more triptan tablets became available: zolmitriptan (1997), rizatriptan (1998), naratriptan (1998), almotriptan and frovatriptan (2001), and eletriptan (2002). An oral film form of rizatriptan (RizaFilm) was FDA-approved in 2023. The zolmitriptan nasal spray was approved in 2003 and is easy to use, with few adverse effects and good efficacy. There is also a new type of sumatriptan nasal spray (approved in 2019) with a permeation enhancer that makes it adhere to the mucous membranes of the nose and allows it to work faster. It does not have the same disliked taste and smell that caused patients to avoid other similar medications. However, most patients still seem to prefer triptans in tablet form over the nasal spray or injection.
Now there are a total of 2 triptan nasal sprays and 7 triptans in tablet form, 2 of which are orally disintegrating tablets (ODT), and there are several sumatriptan injections available that come in 3- 4- or 6-mg dosages.
Do you prefer to prescribe a particular triptan medication to your patients, and if so, why?
Of the different forms of triptans (nasal sprays, tablets, and injections), my favorite is the nasal spray form of zolmitriptan 5 mg (it also comes in 2.5-mg doses, which I sometimes prescribe to pediatric patients). I prefer it because of how quickly it works to provide my patients relief from migraine. All tablets must go down the esophagus, into the stomach, then into the small intestine to the level of the jejunum, where it is absorbed. It then goes to the liver, where it is metabolized, and then (once it finally gets into the bloodstream), it starts working. By contrast, when medication is administered into the nasal cavity, it is quickly absorbed from the mucous membrane and enters the bloodstream there and begins working faster than the tablet does. Zolmitriptan also has fewer side effects than the tablet, and my patients appreciate that. If tablets of triptans do not work, I switch to zolmitriptan nasal spray and, in rare situations, the sumatriptan injection.
When would I switch a patient from a triptan any of the new classes of medicines?
If a patient takes a triptan at the first sign of migraine and it doesn’t begin to work for 2 hours, that is taking too long. If the triptan relieves only 50% of the head pain, there is a good chance that the headache will linger and later return with a vengeance. That would make me consider switching a patient to one of the other types of migraine medications. Even if the patient repeats the triptan at 2 hours after the first one, it probably won’t be very effective at that point. I also want to know if a patient experiences any side effects from the triptan. If they say it works, but they get chest pain, drowsiness, or dizziness and can’t function, I may want to switch them to a newer medication.
Triptans can stimulate the serotonin 1B receptors on the nerves on the small blood vessels in various parts of the body. Because of that, they may constrict blood vessels, such as the coronary arteries in the heart or others in brain, which could possibly lead to a heart attack or stroke or hypertension in some patients. I might switch a medication from a triptan for a patient who is older (over 50), has high blood pressure or cholesterol, has obesity, does not regularly exercise, or has a family history of a heart attack or stroke at an early age. You really don’t want to constrict blood vessels in these patients and should consider a newer therapy.
Can you tell us more about the nasal sprays for acute care of migraine?
Other than the standard sumatriptan nasal spray, the half-dose of sumatriptan nasal spray with a permeation enhancer, and zolmitriptan nasal spray, there are 2 additional options on the market. They are both dihydroergotamine (DHE) mesylate, an ergot alkaloid liquid nasal spray. They are identical chemicals with different devices that produce the sprays. The older DHE nasal spray is called Migranal; it is used 1 time in each nostril, then 15 minutes later is repeated. I feel like it takes too long to get the medicine into the bloodstream because the nasal spray only emits a gentle spray that lays on the bottom of the nose. It doesn’t get to the top or back of the nasal cavity, where there are more blood vessels, which would result in better absorption and efficacy. The second nasal spray is called Trudhesa, which came out just a few years ago when another company took the same exact chemical entity and delivered it with a bigger sprayer that fires it up to the top and back of the nose, where it is better absorbed. That nasal spray seems to work better than the old nasal spray. We don’t have data showing how much better it works than the other, but patients tend to like it more. We may also see a fine DHE nasal powder soon, which may take slightly longer to work but with good efficacy that lasts longer.
Have any adverse events been reported with the DHE nasal sprays for migraine?
A patient may experience some pain or burning in the nose, have a funny taste in the mouth, or even experience a change in the way a food tastes for a while after taking the DHE nasal spray. It could also cause some chest discomfort because it stimulates the same receptors as the triptans, plus other receptors as well.
Are there any newer acute care medications for migraine?
There are 2 newer groups of migraine medications that have come out within the past few years: gepants and a ditan. There are 2 gepants currently available. The first one to be FDA-approved for acute care of migraine (in 2019) was ubrogepant (Ubrelvy), and the second gepant, rimegepant (Nurtec), was approved in 2020. They both work approximately the same way, but they may cause different adverse events. They both sit on the calcitonin gene-related peptide (CGRP) receptors. These receptors are all over the body and the brain, but the place where researchers believe they work most effectively is on the first branch of the trigeminal nerve between the brainstem and the meninges. This is the trigeminovascular system. It works outside of the central nervous system and modulates what goes on inside the central nervous system.
Ubrogepant is a regular tablet that has 2 sizes, 50 and 100 mg. I might start a patient on a 50-mg tablet, and I will instruct them to take another dose (up to 200 mg a day) if they have not improved in 2 hours. Rimegepant comes only as a 75-mg ODT, or fast melt tablet which means a patient can put it on their tongue and they don’t need water with it. For example, if a patient is stuck on an interstate in a traffic jam at rush hour, is getting a terrible headache, and doesn’t happen to have water, they could just place the tablet it in their mouth, where it will dissolve in 5 to 10 seconds. A second dose doesn’t seem to be necessary; if the headache persists, I will switch to another type of medication that day.
The other category of acute migraine medicine that has been approved in the last few years is called a ditan. Only 1 ditan in the class is available right now, lasmiditan (Reyvow). It was FDA-approved in 2019 and works a little bit differently from the gepants, as it’s more like a triptan. Instead of stimulating the serotonin 1B and 1D receptors, it stimulates the serotonin 1F receptor. This is important because it doesn’t stimulate the 1B receptor and therefore doesn’t constrict blood vessels. The one good thing about this medication is it can be prescribed to an older patient or a patient that has any kind of coronary artery risk factors like smoking or obesity. It does enter the central nervous system to begin working, and when a drug does that, it’s more likely to have different side effects, such as dizziness or drowsiness—and this medication does cause both. The drug works well, but the side effects must be carefully observed. Patients are advised not to drive a car or operate machinery for 8 hours after taking this drug.
The advancements in the pharmacologic treatment options for the acute care of migraine offer a wide range of options for patients with migraine—allowing for more personalized and effective approaches for relief, with fewer adverse events than ever before.
MDedge: What were the earliest acute care medications available for migraine?
Dr. Rapoport: In the 1940s, ergotamine tartrate tablets and sublingual tablets were introduced as therapy to treat migraine. They were not that well absorbed, caused nausea, and were not very effective—but they were the only treatment option. Then, beginning in the early 1990s, doctors began prescribing a class of medications called triptans to stop a migraine in progress. Patients are instructed to quickly take the triptan as soon as they know it is or will be a migraine headache; if they wait too long, it may not work as well—or at all. If they don’t have any improvement in 2 hours, they are encouraged to repeat the dosage, even though it often does not work well.
As I strongly recommend to my patients, triptans should not be used more than 2 days per week. An average of 3 days per week or more is too much, and triptan medications can cause medication overuse headache (MOH). If the patient develops MOH, they usually have more headaches rather than fewer—and the medication stops working well.
These medicines work in about 60% of patients and not so well in the other 40%. They do cause side effects in certain people, which may include some pain in their chest or neck muscles and constriction of blood vessels. Some patients also feel a warm-to-hot feeling all over, tingling sensation, drowsiness, dizziness, and other side effects. Some will experience these side effects but continue to take these medications because they work; however, some patients can’t take them because they find the side effects to be too bothersome.
The first triptan to be marketed (in 1992) was a 6-mg, self-injected, subcutaneous injection of sumatriptan (Imitrex). Injection was the only available delivery method for a triptan until 1994, when the tablet form became available.
Typically, patients who hadn’t taken the sumatriptan injections preferred to start with the tablets, but the patients who had been taking the injection form were used to it and preferred to keep taking it. They knew that it worked well, and if they had mild side effects, they weren’t troubled by them. However, most new patients, when given a choice, asked for the tablet instead of the injection. In 1996, sumatriptan nasal spray was introduced, which is inconsistently absorbed, and patients report it does not taste or smell good.
Within a few years, more triptan tablets became available: zolmitriptan (1997), rizatriptan (1998), naratriptan (1998), almotriptan and frovatriptan (2001), and eletriptan (2002). An oral film form of rizatriptan (RizaFilm) was FDA-approved in 2023. The zolmitriptan nasal spray was approved in 2003 and is easy to use, with few adverse effects and good efficacy. There is also a new type of sumatriptan nasal spray (approved in 2019) with a permeation enhancer that makes it adhere to the mucous membranes of the nose and allows it to work faster. It does not have the same disliked taste and smell that caused patients to avoid other similar medications. However, most patients still seem to prefer triptans in tablet form over the nasal spray or injection.
Now there are a total of 2 triptan nasal sprays and 7 triptans in tablet form, 2 of which are orally disintegrating tablets (ODT), and there are several sumatriptan injections available that come in 3- 4- or 6-mg dosages.
Do you prefer to prescribe a particular triptan medication to your patients, and if so, why?
Of the different forms of triptans (nasal sprays, tablets, and injections), my favorite is the nasal spray form of zolmitriptan 5 mg (it also comes in 2.5-mg doses, which I sometimes prescribe to pediatric patients). I prefer it because of how quickly it works to provide my patients relief from migraine. All tablets must go down the esophagus, into the stomach, then into the small intestine to the level of the jejunum, where it is absorbed. It then goes to the liver, where it is metabolized, and then (once it finally gets into the bloodstream), it starts working. By contrast, when medication is administered into the nasal cavity, it is quickly absorbed from the mucous membrane and enters the bloodstream there and begins working faster than the tablet does. Zolmitriptan also has fewer side effects than the tablet, and my patients appreciate that. If tablets of triptans do not work, I switch to zolmitriptan nasal spray and, in rare situations, the sumatriptan injection.
When would I switch a patient from a triptan any of the new classes of medicines?
If a patient takes a triptan at the first sign of migraine and it doesn’t begin to work for 2 hours, that is taking too long. If the triptan relieves only 50% of the head pain, there is a good chance that the headache will linger and later return with a vengeance. That would make me consider switching a patient to one of the other types of migraine medications. Even if the patient repeats the triptan at 2 hours after the first one, it probably won’t be very effective at that point. I also want to know if a patient experiences any side effects from the triptan. If they say it works, but they get chest pain, drowsiness, or dizziness and can’t function, I may want to switch them to a newer medication.
Triptans can stimulate the serotonin 1B receptors on the nerves on the small blood vessels in various parts of the body. Because of that, they may constrict blood vessels, such as the coronary arteries in the heart or others in brain, which could possibly lead to a heart attack or stroke or hypertension in some patients. I might switch a medication from a triptan for a patient who is older (over 50), has high blood pressure or cholesterol, has obesity, does not regularly exercise, or has a family history of a heart attack or stroke at an early age. You really don’t want to constrict blood vessels in these patients and should consider a newer therapy.
Can you tell us more about the nasal sprays for acute care of migraine?
Other than the standard sumatriptan nasal spray, the half-dose of sumatriptan nasal spray with a permeation enhancer, and zolmitriptan nasal spray, there are 2 additional options on the market. They are both dihydroergotamine (DHE) mesylate, an ergot alkaloid liquid nasal spray. They are identical chemicals with different devices that produce the sprays. The older DHE nasal spray is called Migranal; it is used 1 time in each nostril, then 15 minutes later is repeated. I feel like it takes too long to get the medicine into the bloodstream because the nasal spray only emits a gentle spray that lays on the bottom of the nose. It doesn’t get to the top or back of the nasal cavity, where there are more blood vessels, which would result in better absorption and efficacy. The second nasal spray is called Trudhesa, which came out just a few years ago when another company took the same exact chemical entity and delivered it with a bigger sprayer that fires it up to the top and back of the nose, where it is better absorbed. That nasal spray seems to work better than the old nasal spray. We don’t have data showing how much better it works than the other, but patients tend to like it more. We may also see a fine DHE nasal powder soon, which may take slightly longer to work but with good efficacy that lasts longer.
Have any adverse events been reported with the DHE nasal sprays for migraine?
A patient may experience some pain or burning in the nose, have a funny taste in the mouth, or even experience a change in the way a food tastes for a while after taking the DHE nasal spray. It could also cause some chest discomfort because it stimulates the same receptors as the triptans, plus other receptors as well.
Are there any newer acute care medications for migraine?
There are 2 newer groups of migraine medications that have come out within the past few years: gepants and a ditan. There are 2 gepants currently available. The first one to be FDA-approved for acute care of migraine (in 2019) was ubrogepant (Ubrelvy), and the second gepant, rimegepant (Nurtec), was approved in 2020. They both work approximately the same way, but they may cause different adverse events. They both sit on the calcitonin gene-related peptide (CGRP) receptors. These receptors are all over the body and the brain, but the place where researchers believe they work most effectively is on the first branch of the trigeminal nerve between the brainstem and the meninges. This is the trigeminovascular system. It works outside of the central nervous system and modulates what goes on inside the central nervous system.
Ubrogepant is a regular tablet that has 2 sizes, 50 and 100 mg. I might start a patient on a 50-mg tablet, and I will instruct them to take another dose (up to 200 mg a day) if they have not improved in 2 hours. Rimegepant comes only as a 75-mg ODT, or fast melt tablet which means a patient can put it on their tongue and they don’t need water with it. For example, if a patient is stuck on an interstate in a traffic jam at rush hour, is getting a terrible headache, and doesn’t happen to have water, they could just place the tablet it in their mouth, where it will dissolve in 5 to 10 seconds. A second dose doesn’t seem to be necessary; if the headache persists, I will switch to another type of medication that day.
The other category of acute migraine medicine that has been approved in the last few years is called a ditan. Only 1 ditan in the class is available right now, lasmiditan (Reyvow). It was FDA-approved in 2019 and works a little bit differently from the gepants, as it’s more like a triptan. Instead of stimulating the serotonin 1B and 1D receptors, it stimulates the serotonin 1F receptor. This is important because it doesn’t stimulate the 1B receptor and therefore doesn’t constrict blood vessels. The one good thing about this medication is it can be prescribed to an older patient or a patient that has any kind of coronary artery risk factors like smoking or obesity. It does enter the central nervous system to begin working, and when a drug does that, it’s more likely to have different side effects, such as dizziness or drowsiness—and this medication does cause both. The drug works well, but the side effects must be carefully observed. Patients are advised not to drive a car or operate machinery for 8 hours after taking this drug.
The advancements in the pharmacologic treatment options for the acute care of migraine offer a wide range of options for patients with migraine—allowing for more personalized and effective approaches for relief, with fewer adverse events than ever before.
MDedge: What were the earliest acute care medications available for migraine?
Dr. Rapoport: In the 1940s, ergotamine tartrate tablets and sublingual tablets were introduced as therapy to treat migraine. They were not that well absorbed, caused nausea, and were not very effective—but they were the only treatment option. Then, beginning in the early 1990s, doctors began prescribing a class of medications called triptans to stop a migraine in progress. Patients are instructed to quickly take the triptan as soon as they know it is or will be a migraine headache; if they wait too long, it may not work as well—or at all. If they don’t have any improvement in 2 hours, they are encouraged to repeat the dosage, even though it often does not work well.
As I strongly recommend to my patients, triptans should not be used more than 2 days per week. An average of 3 days per week or more is too much, and triptan medications can cause medication overuse headache (MOH). If the patient develops MOH, they usually have more headaches rather than fewer—and the medication stops working well.
These medicines work in about 60% of patients and not so well in the other 40%. They do cause side effects in certain people, which may include some pain in their chest or neck muscles and constriction of blood vessels. Some patients also feel a warm-to-hot feeling all over, tingling sensation, drowsiness, dizziness, and other side effects. Some will experience these side effects but continue to take these medications because they work; however, some patients can’t take them because they find the side effects to be too bothersome.
The first triptan to be marketed (in 1992) was a 6-mg, self-injected, subcutaneous injection of sumatriptan (Imitrex). Injection was the only available delivery method for a triptan until 1994, when the tablet form became available.
Typically, patients who hadn’t taken the sumatriptan injections preferred to start with the tablets, but the patients who had been taking the injection form were used to it and preferred to keep taking it. They knew that it worked well, and if they had mild side effects, they weren’t troubled by them. However, most new patients, when given a choice, asked for the tablet instead of the injection. In 1996, sumatriptan nasal spray was introduced, which is inconsistently absorbed, and patients report it does not taste or smell good.
Within a few years, more triptan tablets became available: zolmitriptan (1997), rizatriptan (1998), naratriptan (1998), almotriptan and frovatriptan (2001), and eletriptan (2002). An oral film form of rizatriptan (RizaFilm) was FDA-approved in 2023. The zolmitriptan nasal spray was approved in 2003 and is easy to use, with few adverse effects and good efficacy. There is also a new type of sumatriptan nasal spray (approved in 2019) with a permeation enhancer that makes it adhere to the mucous membranes of the nose and allows it to work faster. It does not have the same disliked taste and smell that caused patients to avoid other similar medications. However, most patients still seem to prefer triptans in tablet form over the nasal spray or injection.
Now there are a total of 2 triptan nasal sprays and 7 triptans in tablet form, 2 of which are orally disintegrating tablets (ODT), and there are several sumatriptan injections available that come in 3- 4- or 6-mg dosages.
Do you prefer to prescribe a particular triptan medication to your patients, and if so, why?
Of the different forms of triptans (nasal sprays, tablets, and injections), my favorite is the nasal spray form of zolmitriptan 5 mg (it also comes in 2.5-mg doses, which I sometimes prescribe to pediatric patients). I prefer it because of how quickly it works to provide my patients relief from migraine. All tablets must go down the esophagus, into the stomach, then into the small intestine to the level of the jejunum, where it is absorbed. It then goes to the liver, where it is metabolized, and then (once it finally gets into the bloodstream), it starts working. By contrast, when medication is administered into the nasal cavity, it is quickly absorbed from the mucous membrane and enters the bloodstream there and begins working faster than the tablet does. Zolmitriptan also has fewer side effects than the tablet, and my patients appreciate that. If tablets of triptans do not work, I switch to zolmitriptan nasal spray and, in rare situations, the sumatriptan injection.
When would I switch a patient from a triptan any of the new classes of medicines?
If a patient takes a triptan at the first sign of migraine and it doesn’t begin to work for 2 hours, that is taking too long. If the triptan relieves only 50% of the head pain, there is a good chance that the headache will linger and later return with a vengeance. That would make me consider switching a patient to one of the other types of migraine medications. Even if the patient repeats the triptan at 2 hours after the first one, it probably won’t be very effective at that point. I also want to know if a patient experiences any side effects from the triptan. If they say it works, but they get chest pain, drowsiness, or dizziness and can’t function, I may want to switch them to a newer medication.
Triptans can stimulate the serotonin 1B receptors on the nerves on the small blood vessels in various parts of the body. Because of that, they may constrict blood vessels, such as the coronary arteries in the heart or others in brain, which could possibly lead to a heart attack or stroke or hypertension in some patients. I might switch a medication from a triptan for a patient who is older (over 50), has high blood pressure or cholesterol, has obesity, does not regularly exercise, or has a family history of a heart attack or stroke at an early age. You really don’t want to constrict blood vessels in these patients and should consider a newer therapy.
Can you tell us more about the nasal sprays for acute care of migraine?
Other than the standard sumatriptan nasal spray, the half-dose of sumatriptan nasal spray with a permeation enhancer, and zolmitriptan nasal spray, there are 2 additional options on the market. They are both dihydroergotamine (DHE) mesylate, an ergot alkaloid liquid nasal spray. They are identical chemicals with different devices that produce the sprays. The older DHE nasal spray is called Migranal; it is used 1 time in each nostril, then 15 minutes later is repeated. I feel like it takes too long to get the medicine into the bloodstream because the nasal spray only emits a gentle spray that lays on the bottom of the nose. It doesn’t get to the top or back of the nasal cavity, where there are more blood vessels, which would result in better absorption and efficacy. The second nasal spray is called Trudhesa, which came out just a few years ago when another company took the same exact chemical entity and delivered it with a bigger sprayer that fires it up to the top and back of the nose, where it is better absorbed. That nasal spray seems to work better than the old nasal spray. We don’t have data showing how much better it works than the other, but patients tend to like it more. We may also see a fine DHE nasal powder soon, which may take slightly longer to work but with good efficacy that lasts longer.
Have any adverse events been reported with the DHE nasal sprays for migraine?
A patient may experience some pain or burning in the nose, have a funny taste in the mouth, or even experience a change in the way a food tastes for a while after taking the DHE nasal spray. It could also cause some chest discomfort because it stimulates the same receptors as the triptans, plus other receptors as well.
Are there any newer acute care medications for migraine?
There are 2 newer groups of migraine medications that have come out within the past few years: gepants and a ditan. There are 2 gepants currently available. The first one to be FDA-approved for acute care of migraine (in 2019) was ubrogepant (Ubrelvy), and the second gepant, rimegepant (Nurtec), was approved in 2020. They both work approximately the same way, but they may cause different adverse events. They both sit on the calcitonin gene-related peptide (CGRP) receptors. These receptors are all over the body and the brain, but the place where researchers believe they work most effectively is on the first branch of the trigeminal nerve between the brainstem and the meninges. This is the trigeminovascular system. It works outside of the central nervous system and modulates what goes on inside the central nervous system.
Ubrogepant is a regular tablet that has 2 sizes, 50 and 100 mg. I might start a patient on a 50-mg tablet, and I will instruct them to take another dose (up to 200 mg a day) if they have not improved in 2 hours. Rimegepant comes only as a 75-mg ODT, or fast melt tablet which means a patient can put it on their tongue and they don’t need water with it. For example, if a patient is stuck on an interstate in a traffic jam at rush hour, is getting a terrible headache, and doesn’t happen to have water, they could just place the tablet it in their mouth, where it will dissolve in 5 to 10 seconds. A second dose doesn’t seem to be necessary; if the headache persists, I will switch to another type of medication that day.
The other category of acute migraine medicine that has been approved in the last few years is called a ditan. Only 1 ditan in the class is available right now, lasmiditan (Reyvow). It was FDA-approved in 2019 and works a little bit differently from the gepants, as it’s more like a triptan. Instead of stimulating the serotonin 1B and 1D receptors, it stimulates the serotonin 1F receptor. This is important because it doesn’t stimulate the 1B receptor and therefore doesn’t constrict blood vessels. The one good thing about this medication is it can be prescribed to an older patient or a patient that has any kind of coronary artery risk factors like smoking or obesity. It does enter the central nervous system to begin working, and when a drug does that, it’s more likely to have different side effects, such as dizziness or drowsiness—and this medication does cause both. The drug works well, but the side effects must be carefully observed. Patients are advised not to drive a car or operate machinery for 8 hours after taking this drug.
The advancements in the pharmacologic treatment options for the acute care of migraine offer a wide range of options for patients with migraine—allowing for more personalized and effective approaches for relief, with fewer adverse events than ever before.