How is migraine treated?

There are two avenues of migraine therapy: abortive therapy and preventative therapy. Abortive therapy includes medications such as triptans, and anti-inflammatories to stop or at least limit headache progression. Triptans are specific medications developed for stopping the blood vessel changes that develop early in migraine. They promote vasoconstriction (vessel narrowing) and limit the release of inflammatory compounds that trigger the migraine process. They are best used as early as possible with early headache or prodromal aura. They may also be more effective with a non-steroidal such as ibuprofen or naproxen.

With escalating migraine frequency and difficulty migraine control with abortive therapies, preventative therapy is essential to reduce disability from migraine and prevent migraines from becoming a daily occurrence. Tablet therapies can be effective reducing headache severity and frequency. There are many types of medications, some are antidepressants or anti-epileptic medications that also work in migraine prevention. Other medications that may be selected include medications that have other roles in blood pressure and heart rate. The reasons why each individual medication works is unclear, and probably a reflection of the vascular, inflammatory and neuronal signalling aspects of how migraines cause disability.

Over the last 10 years or so, advances in migraine research have led to the discovery of injectable therapy known as cGRP antagonist therapy. These include Ajovy and Emgality. These are specific injections given monthly under the skin via a pen device that work directly to target the inflammatory component of migraine. They are highly effective at reducing migraine intensity and severity in many individuals. Equivalent tablet therapies are also available, including Nurtec, but are not yet available on the PBS and are quite expensive.

Botulinum toxin injections or “botox” therapy is another option on the PBS. Botox injections for migraine involve at least 30 small injections around the eye, upper forehead, sides and back of the head and neck. Additional injections may be given in areas of concern including the jaw muscles, particularly in people with concurrent TMJ dysfunction contributing to migraine. Botulinum toxin also has multiple ways of reducing migraine severity and intensity, both as a muscle relaxant, and pain modulation properties. Unlike the other therapies, botox only works at the site of injection and does not typically enter the blood stream, eliminating the concern over wide-spread bodily side effects. Both botulinum toxin and cGRP injectable pen therapies are available on the PBS, but at least three preventative therapies would have need to be tried or be contraindicated. Botox upfront is available off-label, and cost is generally reasonable, but may be prohibitive for many.

Other treatments may include greater occipital and supraorbital nerve blocks. This is an injection of local anaesthetic and corticosteroid into nerve regions to produce local nerve blockade. This is often used as a rescue therapy in severe migraine attacks in the hospital setting. Intravenous antinausea medications including “Largactil” are additionally offered in hospital as a rescue medication and effective in many cases.

Other therapy, including massage therapy, B2 and magnesium supplementation, peppermint oil rub and ginger supplements may also be tried, in conjunction with medical therapy. The efficacy in these is mixed.