Individuals that suffer from migraines can have these as infrequently as once a year, to as frequently as almost every day. The approach to preventing and treating migraines depends in large part on how frequently someone has these headaches. For someone with migraines as infrequent as once a week, we generally only recommend one of the medications that can be taken to quickly terminate the headaches when they occur. There are medications that can be taken daily to prevent migraines, but this does not seem justifiable with infrequent headaches. Some people with these infrequent migraines also appear to benefit from physical therapy. Yoga may also be helpful at reducing these headaches, and in my experience with patients this has been positive with reasonable consistency. Finally, there is some recent evidence that at least implies migraines may benefit from neck strengthening exercises.
For people with more frequent migraines, there are now a large variety of options to choose from to prevent the headaches. Typically, when such patients come to see us they have already tried chiropractic, massage, or physical therapy without success. None of the preventive medications work 100% of the time, most are helpful around 50% of the time, so it is necessary to try a series of different medications to find what works, and these medications are frequently added to one another for additional benefit. The list of such medications keeps growing and growing, and the selection of which agent to use is largely dependent on any other conditions a patient may have, side effect profile, effectiveness, and insurance coverage. It generally requires several months to find a treatment that consistently reduces migraines, though we rarely completely eliminate them.
Most of the medications we use for preventing migraine were only incidentally found to be helpful. For example, TopamaxTM (topiramate) was developed to treat seizures, and incidentally found to be helpful for migraine. BotoxTM is also approved for preventing frequent migraines, but its effectiveness was incidentally discovered while treating wrinkles. Recently, a class of medications that were specifically developed to prevent migraine have become available, for example AimovigTM and AjoviTM, and these are reasonably effective.
Many patients with frequent migraine have an irregular sleep-wake cycle and there is some evidence that making this cycle more regular also improves migraine control.
A popular concept amid headache specialists is the idea that taking medication to acutely terminate the headaches too frequently can cause more frequent headaches. This is called a "medication-overuse-headache". In our review of the literature, we find very little to no high quality evidence to support this concept. It is of course common to find people whose headaches have been increasing and their use of acute headache relief medication has increased also, but we find it more plausible that it is the worsening headaches that are driving the medication use, not the medication use driving the worsening headaches. In patients taking frequent acute headache relief medication, we focus on finding the right preventive medication, and typically find their use of acute relief medication gradually tapers off.
However, frequent use of narcotic or opioid pain medication by migraine sufferers is strongly recommended against. When we review our patient charts of people who did and did not respond to the more effective treatments, a markedly disproportionate number of poor responders are taking frequent opioid or narcotic pain medications. Additionally, most experienced headache specialists know patients taking frequent doses of such medications rarely get better. There is actually a recognized phenomenon in which taking such medications over the long term can make people even more sensitive to pain, and this is called opioid-induced hyperalgesia. Amazingly, no one knows how frequent this phenomenon is, despite how widely these medications are used and abused.
