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For the 37 million-plus Americans who suffer from migraines, treatment may start to look different.
The American Academy of Neurology recently revised its migraine prevention and treatment recommendations for the first time in almost 15 years, offering fresh guidance for doctors and patients looking for solutions to the painful and often debilitating neurological condition.
One of the biggest changes: Broadening who qualifies for treatment and updating which treatments are suggested first. Previously, to be considered for preventive care, a patient had to have eight or more migraines a month. That number has been cut in half to just four, according to the new guidelines.
Additionally, a class of drugs called calcitonin gene-related peptide (CGRP) inhibitors, a newer treatment for migraines, are now considered first-line defense medications alongside the more traditional ones already in use.
With new recommendations in place, how you talk to your doctor and what treatments are offered to you may change. Check this quick guide on the biggest takeaways, treatment options and what to expect if you’re considering or are in treatment for migraines or severe headaches.
When should you ask about preventive treatment for migraines?
You may want to start a conversation with your doctor about migraine prevention treatments if:
- You have four or more moderate to severe headache days each month
- You miss work, school, family activities or social events due to migraines
- As-needed medications meant for temporary relief aren’t enough to manage pain
Choosing your treatment goals
The right treatment for you isn’t based solely on symptoms. Considerations like cost, side effects and frequency can dictate what works for each person’s situation. Think about what your primary goals or concerns are to discuss with your doctor.
Goal: The most effective options for preventing migraine
Tips: Ask about drugs with the strongest evidence of reducing migraine frequency, including:
- Atogepant
- Eptinezumab
- Erenumab
- Fremanezumab
- Galcanezumab
- Topiramate
- Propranolol
- Valproate
- Botox (for chronic migraine)
Goal: Fewer side effects
Tips: Ask about drugs that have fewer side effects and were best tolerated in clinical trials, including:
- Atogepant
- Eptinezumab
- Erenumab
- Fremanezumab
- Galcanezumab
- Botox (chronic migraine)
Goal: Lower cost
Tips: Insurance companies tend to prefer generic medications, which are generally most affordable for people with and without insurance. Ask if a generic medication could work for you, including:
- Propranolol
- Topiramate
- Amitriptyline
Pills, injections, infusions: finding the right medication
The good news for migraine sufferers is that there are options. If you have a phobia of needles or struggle to remember to take a daily pill, there are other treatment types.
Daily pills
For patients who prefer to avoid injections and don’t mind staying on top of a daily regimen, pills like Atogepant, Topiramate, Propranolol and Amitriptyline are an option.
Side effects depend on the medication. Common ones include fatigue, dizziness and gastrointestinal symptoms like diarrhea, constipation or stomach upset.
Monthly injections
If you’re more “one and done” and prefer less frequent treatments, you can opt for monthly injections like Erenumab, Fremanezumab and Galcanezumab.
These are a class of drugs called calcitonin gene-related peptide (CGRP) antagonists. CGRP-targeted therapies were newly added to the recommendations as a first-line option that can be used alone or alongside other medications. These drugs work by blocking the effects of CGRP, a protein present in the sensory nerves connected to the head and neck that can cause migraines, according to the Cleveland Clinic.
Some CGRP drugs also come in pill form, such as Atogepant.
Side effects depend on the medication but commonly include injection-site pain, redness or swelling, allergic reactions of varying degrees and possible high blood pressure.
Quarterly infusions
If you’re not needle-shy and want to go even longer between treatments, quarterly infusions are also an option. The drug Eptinezumab can be given intravenously (through an IV) every few months.
Eptinezumab is also a medication that targets CGRP. It is usually given every 12 weeks and is associated with mild side effects such as a stuffy nose, scratchy throat and allergic reactions.
Botox, which is generally reserved for chronic migraine sufferers, is also administered on a 12-week schedule. While many associate it with cosmetic procedures, Botox injections into specific muscles in the head, neck and shoulders can allow the drug to reach the nerves that trigger migraines and block the pain signals from them, according to Cleveland Clinic.
Extra considerations
Other conditions, like high blood pressure, fibromyalgia, obesity and headaches prompted by medication overuse, are common comorbidities for which there are preferred treatments.
For example, Enalapril, Nifedipine, or Telmisartan can help manage blood pressure, and Amitriptyline may improve both migraine and fibromyalgia symptoms.
Pregnancy is also a significant factor in choosing treatment. Some doctors and patients who are or could become pregnant may opt for a non-medication approach, such as exercise, trigger management, behavioral therapy and acupuncture. If medication is necessary, Nifedipine, propranolol, metoprolol, or Botox may be preferred options.
What to expect
Although treatments can take a while to begin working, it’s important to continue the course as prescribed until you can speak with your doctor.
- Medications: It generally takes 8-12 weeks of a therapeutic dose to determine whether a medication is successful.
- Botox: It takes about 24 weeks (or about two rounds of treatment) to determine if Botox is effective.
Your doctor may ask you to keep a headache diary to measure your progress, track migraine days, rate severity, note missed activities and manage as-needed medications. Doctors may also use in-office assessments and tests to determine whether treatment is working.
Some things you may want to ask your doctor while discussing treatment include:
- Which preventive treatment best matches my goals?
- What side effects should I expect?
- How long should I try it before deciding whether it works?
- Could one medication affect both my migraine and another health condition?
- Will my insurance cover this treatment?
- What should I do if I plan to become pregnant?
- How will we measure success?