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Defining the "Right" Treatment for Migraine Headaches


As a neurologist who has cared for many patients experiencing migraines and chronic headaches, I can confidently state that rarely are two patients’ experiences the same. What one person may find debilitating, another may experience as only a nuisance. Some people can maintain a high quality of life with specific headache symptoms, while others may be unable to work or live well while experiencing those symptoms. Alas, migraine headaches can be as unique to the individual as a fingerprint.

With June designated as Migraine and Headache Awareness Month, it feels like an appropriate time to discuss the current standards of care for migraine headaches, the advantages and limitations of available treatment options, and ways for people who experience migraines to determine what the “right” treatment is for their unique set of circumstances.

A basic tenet of any migraine treatment is the need to understand that this can be a progressive condition, which may escalate and worsen if not treated appropriately. The “Stratified Care” approach to migraine treatment that this neurologist prescribes advocates for individualizing the intensity and aggressiveness of intervention based on the severity of the headache in the individual. Less aggressive and more conservative approaches are reasonable if there is mild or moderate effect on an individual’s function, quality of life, or safety. However, as the severity and consequence of the migraines increase, it is reasonable to be more aggressive in treatment – without adhering to a “stepwise” approach of intervening with conservative measures, then evaluating response and escalating after proving a failure. In other words, bringing out the big guns (aggressive intervention) may be recommended with severe or potentially consequential migraine headaches – even early on. Also, attention is paid to abortive treatments (to stop a migraine that has started) and prophylactic treatment (daily or routine intervention for prevention and reduction in severity or frequency). I also round out this approach with a recommendation to include holistic treatment approaches. That means avoiding triggers, optimizing sleep and overall well-being, reducing stress, and exercising regularly.

Traditional medication treatments are many and also fall into the abortive and preventive categories. Migraine medications aim to either stop an episode quickly once it has begun or to prevent it from happening in the first place. Medication therapy for migraine headaches, like medication for most other conditions, diseases, or illnesses, can come with plenty of side effects that patients may find as undesirable as the migraine itself. However, a relatively new and promising category of medications act on specific brain receptor - the Calcitonin Gene-Related Peptide Receptors (CGRP). These drugs are developed specifically for migraine treatment. They may more directly impact the pain and symptom pathways specific to migraine than other medications that have historically been available. In addition, there is increasing interest in neuromodulation (applying electrical or magnetic stimulation to nerves) as a treatment for migraine that doesn’t require prescription drugs.

All these approaches augment and build on current practices. The migraine treatment toolbox is expanding for patients and caregivers alike– and that’s a great development. It must, however, be accompanied by improved education, recognition, and access for all to the emerging options. Too often, there are recommendations made that may be helpful to a wide range of individuals. Yet, plenty of migraine sufferers lack insurance coverage or the financial/economic ability to pursue state-of-the-art treatments available to everyone who needs and deserves them.

Additional work is needed to level the treatment playing field by addressing some of the health equity issues we see in the diagnosis and treatment of migraine. There is also a need to further refine our approach to migraine treatment that results from or increases after concussion and other forms of traumatic brain injury. Finally, the emergence of modern pain science provides an opportunity to influence migraine treatment by recognizing how migraine mechanisms compare to other forms of chronic pain and the role of social and environmental risk factors in the development of migraine. If they haven’t already, those who suffer from chronic migraines should make it a priority to seek out medical attention. A neurological expert can help find ways to cope with migraines so that patients don’t suffer in silence.