Migraine

Non-Surgical Migraine Treatments

Not all people with migraines respond the same way to each treatment. Physicians at UT Southwestern Medical Center work with each patient to determine what approach works best to stop migraine symptoms, prevent their recurrence, or reduce their frequency and severity.

Migraine Triggers

A primary treatment for migraines is to eliminate migraine triggers. At UT Southwestern, migraine specialists encourage patients to keep a diary or calendar of their migraines to determine whether any cause-effect relationship is present. 

Below is a list of common triggers, and there might be others.

Food and Drink

A variety of food and beverages have been associated with migraines, such as:

  • Aged cheeses
  • Beverages containing alcohol and sulfites (especially wine)
  • Caffeine
  • Chocolate
  • Citrus fruits
  • Dyes or other chemical food additives
  • Foods containing tyramine or nitrites (smoked/cured deli meat, luncheon meats, hot dogs, bananas, avocados)
  • Onions
  •  Monosodium glutamate or MSG (found in Chinese food, commercial pizza, many processed food products; also described as a “flavor enhancer”)
  • NutraSweet®
  • Olean®
  • Peanuts
  • Pickled foods

Stress

Stress can trigger a migraine or make migraine symptoms worse. Some patients notice that migraines are worse after a stressful period is over, such as on the weekend or the first day of vacation.

Environment

Certain odors (strong perfumes, fumes, etc.), very bright lights, or loud noises can trigger migraines. Some people develop a migraine if their sleep pattern changes. They can prevent migraines by waking up at the same time each day, even on the weekend. Migraine is often triggered by changes in the weather, sometimes leading to the incorrect diagnosis of “sinus” headaches.

Symptomatic Treatment

Symptomatic treatment works best for people who have infrequent headaches. The use of pain medication – even over-the-counter medications – more than two or three times a week can make headaches worse and less likely to respond to preventive treatments. Patients can develop medication overuse headaches as a result. 

The most common types of symptomatic treatments include:

  • Anti-emetic medications: Helpful for people who have nausea and vomiting. Suppositories are a good option for people with severe vomiting. Drowsiness is a common side effect.
  • Anti-inflammatory/analgesic medications: These include aspirin, ibuprofen, and similar medications (naproxen). The most common side effects of these medications are upset stomach and dizziness. Acetaminophen (Tylenol)-containing medications can also be effective.
  • Combination preparations: Compounds might contain an analgesic (aspirin or acetaminophen), narcotic analgesic, sedative, and an agent to constrict blood vessels (caffeine). Commonly used preparations include butalbital (Fiorinal, Fioricet), Excedrin, Midrin (not commercially available), or Bellergal. Over-the-counter preparations might include an analgesic, magnesium, feverfew, or riboflavin.
  • Dihydroergotamine (DHE): DHE affects serotonin and constricts blood vessels, primarily veins. DHE produces nausea and requires pretreatment with an anti-emetic. It can be given by injection (into a vein, muscle, or below the skin), by nasal spray (Migranal), or capsule. (Capsules are not commercially available.)
  • Narcotics and opioids: Medications such as codeine, hydromorphone, oxycodone, or hydrocodone for severe pain control generally don’t work well for migraine. They also cause drowsiness, might produce or worsen nausea, and can be addictive.
  • Sedatives: Induce sleep. Prolonged use of sedatives is not recommended.
  • Triptans: These include sumatriptan (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt), zolmitriptan (Zomig), almotriptan (Axert), frovatriptan (Frova), eletriptan (Relpax), and sumatriptan/naproxen (Treximet) and are available as tablets, nasal sprays, and injections (under the skin). Relief usually occurs in 30 to 60 minutes (sooner with injectable form and nasal spray). Medications can be used twice daily. The triptans should not be used with basilar migraine, in people with coronary artery disease, or during pregnancy. They cannot be used within 24 hours of each other or with DHE. They work best when taken early in the headache process. 

Some of these treatments can be combined. The neurological and visual symptoms of migraine cannot be treated with symptomatic treatment. 

Non-Pharmaceutical Treatment

Several other techniques have shown benefit for people with migraines, such as:

  • Cognitive behavioral therapy
  • Biofeedback
  • Exercise
  • Physical therapy
  • Relaxation therapy
  • Stress management

Preventive Treatment

In addition to symptomatic treatment, people with frequent, debilitating headaches might prefer to take daily medication to prevent migraines. These preventive medications were originally developed for other conditions and later shown to be effective for migraine. They include various types of:

  • Anti-epileptics such as semisodium valproate (Depakote), topiramate (Topamax), gabapentin (Neurontin): Initially marketed for the treatment of epilepsy, these drugs are also useful in the treatment of headache. The dose is typically much lower than when used for seizures. Valproate can cause tremor, hair loss, stomach upset, and sedation but is better tolerated in the long-acting preparation. It rarely causes bone marrow problems and liver malfunction. Topiramate might produce sedation, difficulty thinking clearly, weight loss, tingling, kidney stones (rarely), and sudden glaucoma. Sedation and confusion are possible side effects of gabapentin.
  • Anti-inflammatory drugs: Daily use of these medications increases the risk of ulcers, intestinal bleeding, or liver problems.
  • Aspirin: Daily aspirin works by preventing platelets from adhering to each other and affects serotonin levels. A low dose (one 325 mg adult aspirin or one 80 mg aspirin) daily is often effective. Daily aspirin might cause easy bleeding and bruising and should be discontinued at least three days before surgery or dental work. Aspirin can also cause an ulcer and should be avoided in people with pre-existing ulcer disease. Taking aspirin with a full stomach or taking coated aspirin can help with stomach irritation.
  • Beta blockers propranolol (Inderal), nadolol (Corgard): This group of drugs has been a mainstay of migraine prevention for many years. Some headache specialists caution against their use with basilar-type migraine, so they are not usually used as first-line treatment in these patients. The medication has to be taken two to four times daily, but long-acting preparations can be used when the optimum dose is found. The most common side effects are sleepiness, fatigue, low blood pressure, and sexual dysfunction. These medications cannot be used in people with asthma or congestive heart failure, and they should be used with caution in diabetics.
  • Calcium channel blockers verapamil (Verelan), amlodipine (Norvasc): These medications work by stabilizing blood vessel walls to prevent spasm. They are most useful to treat complicated migraine/migraine equivalents, especially for transient visual loss in one eye. They are also effective for migraine headaches. They are taken two to three times daily, and long-acting preparations are available. Side effects include dizziness, swelling, and constipation. These drugs cannot be used in people with an abnormal heart rhythm, liver disease, or kidney disease.
  • Onabotulinum toxin (Botox): Injections are used successfully in many patients who do not have relief with other preventive treatments. They are approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic migraine.
  • Other antidepressants such as fluoxetine (Prozac), venlafaxine (Effexor), bupropion (Wellbutrin): Often helpful alone or in combination with other preventative medications, these medications have an effect on headache, independent from the antidepressant effect, and are helpful for people with headaches and mood disorders. As a group, common side effects include tremor, upset stomach or nausea, and vivid dreams.
  • Tricyclic antidepressants such as amitriptyline (Elavil), nortriptyline (Pamelor), protriptyline (Vivactil): After they were marketed for depression, these medications were found to be very effective in various neurological pain syndromes, including headaches and migraine phenomena. They are usually effective for migraines in much lower doses than those used for treating depression. To avoid excessive sedation, these medications are usually introduced in low doses at bedtime and gradually increased. The most common side effects include sedation (especially with amitriptyline) or insomnia, dry mouth, constipation, rapid heart rate, and weight gain. Most patients notice that they get a headache if they miss a dose. These drugs should not be stopped suddenly, if possible.

Other treatments that can prevent migraines or reduce their frequency include:

  • Vitamin B2
  • Coenzyme Q
  • Magnesium
  • Nerve blocks, for both acute and preventive treatment
  • Antipsychotic medications
  • Antihypertensive drugs
  • Surgery