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Treatment
By LAUREN PAIGE KENNEDY

Medications, Treatments, and Habits that Can Help Migraine

Actress and singer Kristin Chenoweth says vestibular migraine and Meniere’s disease almost ended her career. Today, thanks to avoiding triggers such as bright light and poor sleep and regular injections of abotulinum toxin A (Botox), the Broadway star is still going strong. In the 25 years since Chenoweth’s diagnosis, many new drugs have been approved to treat migraine. Here’s a look at the full range.

Woman dosing medication

In May 2018, the US Food and Drug Administration (FDA) approved the first medication developed specifically to prevent chronic migraine in adults. Called erenumab-aooe (Aimovig), it was developed by Amgen and Novartis, and was the first among a new class of medications that target the calcitonin gene-related peptide (CGRP), a vasodilator that plays an important role in the cardiovascular system and in pain modulation, according to a 2017 article in the Journal of Neurology. Two other medications in the same drug class—fremanezumab (Ajovy) from Teva and galcanezumab-gnlm (Emgality), developed by Lilly—were also approved in 2018.

“Research shows that CGRP levels rise during migraine,” says Robert Cowan, MD, FAAN, professor of neurology and chief of the division of headache medicine at Stanford University. “Blocking the activation of the peptide reduces migraine pain in many patients.”

While the new CGRP drugs may reduce the severity and frequency of symptoms in some people with chronic migraine, none will prevent all migraine attacks, and not everyone responds well to these medications.

Side effects are still being studied, says Dr. Cowan. “Most recently, Amgen had to amend its packaging to acknowledge significant gastrointestinal complications, particularly severe constipation, with the use of Aimovig. We are just beginning to learn about the side effects in subpopulations of people with migraine. Time will tell.”

“Between 1 and 3 percent of people reported side effects of constipation in clinical trials. Injection site reactions are also somewhat common, and hypersensitivity may occur,” says Teshamae Monteith, MD, FAAN, associate professor of clinical neurology and chief of the headache division at the University of Miami Miller School of Medicine. “However, constipation is common with some other established treatments such as tricyclic antidepressants,” she says, noting that patients are encouraged to report side effects to the FDA at fda.gov/medwatch or 800-FDA-1088. “The lack of drug-drug interactions with CGRP medications may benefit patients who take multiple medications for other conditions,” she adds.

Dr. Cowan says he prescribes CGRPs to people similar to those who participated in the clinical trials in terms of age, medication use, and coexisting conditions. “I also may give them to patients who have tried all else without a good response, and who understand the risks of using a drug that was approved only recently.”

Dr. Monteith agrees. “Some studies show that despite being on three or four prior preventives, people may still respond to these injectables. For those who think they’ve tried everything, this may be another way to reduce migraine disability. But certainly not a cure.”

Historically, people have treated migraine symptoms with medications that were originally developed for depression, hypertension, spasticity, or seizures. OnabotulinumtoxinA (Botox) injections, for example, were approved in 1989 to treat spasticity, says Dr. Loder. For many people with migraine, these established therapies effectively alleviate acute and/or chronic symptoms, she adds.

Traditional treatments fall into three categories:

Prevention

Drugs prescribed to keep a migraine from starting include blood-pressure-lowering medications, such as calcium channel blockers and beta blockers; antidepressants and anti-seizure drugs; and Botox injections. “All can be prescribed to reduce the frequency and severity of migraine attacks,” says Dr. Loder. The medications aren’t for everyone, and each comes with a wide range of side effects, she notes.

Pain relief

This group of medications includes triptans and dihydroergotamine (DHE), which block pain pathways in the brain, says Nina Y. Riggins, MD, assistant clinical professor in the division of headache and facial pain at the University of California San Francisco. “Triptans bind to serotonin receptors in the brain and increase the effect of serotonin on pain and mood. DHE similarly amplifies the effects of serotonin. It also works on other receptors, including dopamine,” Dr. Riggins explains. Both triptans and DHE narrow blood vessels, she adds. “Because these medications can constrict vessels, they may not be safe for people who are at risk for heart attack or stroke. Anti-nausea drugs are also prescribed. Opioids, on the other hand, should be avoided whenever possible.”

Healthy habits

Incorporating lifestyle changes and avoiding triggers can be life-changing, says Dr. Cowan. “Eliminating caffeine and red wine may help some people with migraine,” he says. “Keeping a headache journal to understand your triggers is really important.” He also recommends reducing stress—which can be a trigger for migraine—with regular exercise, meditation, and yoga, and combating anxious or unhelpful ways of thinking with cognitive behavioral therapy. “Getting consistent sleep is paramount,” he adds.