Lifestyle modifications have a proven major role in the treatment of migraine headaches. These include diet, exercise, the avoidance of triggers, and stress management. When lifestyle modifications and abortive treatments fail, there is the option of preventative treatment for migraine headache. Preventative treatment options include nutraceutical, pharmacologic and procedural treatments:
A. Nutraceutical and herbal treatment
There are three supplements that have proven efficacy in migraine:
- Magnesium, which is a mineral
- Riboflavin, which is a vitamin also known as B2
- Co-enzyme Q10 (CoQ10), which is an antioxidant
- Feverfew is a plant that can be used as a preventive treatment for migraine.
- Butterburs is an herbal supplement, which comes in a variety of formulations, including capsules, powders, tinctures, and tea and can be used in migraine prevention.
- Patient should be especially careful when using these products since there is no FDA regulation, and we often see advertisement by non-specialist who promote their own proprietary blend of supplements or even offer some non-approved vitamin infusion as migraine treatment, some of which costly and can have negative effects. Therefore, patients should always discuss the using and dosage of these supplements with their treating physician to decide if a specific supplement is right for them.
- More information about the use of nutraceuticals and herbal treatment can be found in the following link : https://truptigokanimd.com/
B. Pharmacological treatment
There are numerous medications used for migraine prevention. There is no guideline or algorithm for choosing preventive treatment. The choice of medications should be based on the patient’s medical and psychological comorbidities and lifestyle.
Also, patients should play an active role in medication choice. However, in the real world, insurance companies play a major role in medication selection, which is unfortunate.
Preventative medication used for migraine could be oral tablets, which patients take daily or can be in the form of injection/infusion, which is performed monthly or quarterly:
Oral preventive treatment – There are three main classes of medication which approved for migraine prevention:
- Antidepressant: Amitriptyline (Elavil), nortriptyline (Pamelor), and Venlafaxine (Effexor) are the most commonly used medications in this class.
- Antihypertensive (Blood pressure medication): Propranolol (Inderal), Metoprolol, Nadolol, Amlodipine (Norvasc), and candesartan (Atacand) are the most commonly used medications in this class.
- Anti-epileptic (seizure medication): Topiramate (Topamax, Trokendi, Qudexy) and Valproate (Depakote) are the only approved treatments from this class of drugs.
- Any other medications besides those listed are considered “off-label” treatment options.
Injection or infusion treatment: These are migraine-specific preventive treatments which have been available since 2018:
- AIMOVIG: comes as autoinjector with two dosages of 70 mg and 140 mg, which need to be injected subcutaneously once a month.
- EMGALITY: comes as autoinjector with 120 mg dose. The first month requires two subcutaneous injections, which is followed by one injection every month thereafter.
- AJOVY: comes in both autoinjector and prefilled syringes with 225 mg doses. It can be injected (subcutaneously) once a month or 3 injections together every 3 months.
- VYEPTI: This is an IV infusion (intravenous), which needs be done every 3 months (4 times a year).
For more information about pharmacologic treatment please visit the following resource link: https://americanmigrainefoundation.org
C. Procedural treatment
Considering potential side effect of medication plus the fact that not all patients respond to medical treatment, different procedures can be uses as treatment of migraine headache:
- Botox injection: This is the only FDA approved procedure for the treatment of chronic migraine. After over a decade of using this injection, its high efficacy and low side effect properties, particularly if performed by an experienced physician, is reassuring. This is an outpatient/office procedure and patients can return to work immediately after the procedure. It is approved to be done every 12 weeks, however in some patients due to faster wearing off, injections need to be done every 10 weeks. For more information visit: https://www.botoxchronicmigraine.com
- Nerve Block: Injection of the nerve(s) with local anesthetic, like lidocaine, has been used for both abortive and the preventive treatment of migraine and other types of headache for many years. This also is an in-office procedure with incredibly low complications. Nerve block can be done on any nerve on head, face and neck that is tender in exam or patient reports as area that pain initiated. Therefore it is important for the patient who are going to have nerve block to keep a detail headache chart with attention to the area that pain initiates (which is also known as trigger point). Nerve block is particularly is a great option for migraine patients who does have single trigger point. Often, a brief course of treatment will result in sustain relief. However, nerve blocks are still considered experimental procedure despite it is a routine procedure in most headache centers. Nerve block should not be mistaken with trigger point injection, which is mainly for tension headache. Since some patients with migraine, particularly chronic migraine, can have tension component, sometime during nerve block, trigger point injection also performs.
- Trigger point deactivation surgery: Surgical procedure for migraine treatment is offered to patients based on their symptoms and qualifications. The procedure, based on the concept of Trigger Point, has been offered to patients by migraine surgeon since early 2000s and first text book of migraine surgery published in 2018 prior to the procedure, the determination of the trigger point(s) needs to be completed by a headache specialist and that is done by collecting a detailed history, head/neck exam or by a CT scan of sinuses in patients who might have intranasal trigger point. Depending on the trigger point(s), the type of procedure may vary, this is why the collaboration of a headache specialist with the migraine surgeon is particularly important to maximize the success of the surgery and to achieve better results. With that in mind, the procedure is performed on an outpatient basis with local or general anesthesia which in the hands of an experienced migraine surgeon can be completed in less than an hour. This particular procedure has a low risk and no major complications indeed; therefore, patients who do not respond to standard migraine treatment or patients who do not want to use medication, this surgery could be an alternative.
We emphasize that, the key to a successful surgery is the proper selection of a headache specialist that collaborates well with an experienced migraine surgeon. More information about this can be found at this link.
D. Facet injection
This procedure requires the use of fluoroscopy or ultrasound and is performed by a pain specialist. This procedure involves the injection of a local anesthetic with steroid into the painful joint in the cervical spine. A very small percentage of migraine patients require this type of intervention and patient selection for this procedure is done by a headache specialist. More information about this procedural treatment option can be found at https://interventionalheadache.net