Migraine Quiz

Treat Your Migraine Attacks Early

When To Treat, and When Not To Treat

It's important to know when you should treat your headaches as well as when not to treat them. We have talked elsewhere about overusing medications, and avoiding the trap of medication overuse headache. It's also important to know that early treatment of a migraine can make a real difference.

You should treat a migraine attack in the mild-to-moderate stage, well before the pain becomes severe. This way, the medication can work on the appropriate brain receptors (targets) to kill your migraine attack before it becomes entrenched. There is sometimes a tendency to wait too long, hoping maybe it isn’t really a migraine after all. Maybe we think we won’t really need our medication, or maybe we think a cup of coffee or eating a meal will do the trick. It's possible that waiting too long to treat your headaches might itself be a symptom. Your brain may be foggy due to the migraine, and you may not be making wise decisions.

The reason you should treat your migraine in the early stages is that migraine medications will be more effective if taken then, when the headache is in the mild to moderate stages.  If you wait too long, more stubborn neurotransmitters become involved, and the headache becomes more resistant.

When  Not To Treat—Avoiding Risk of Medication Overuse

If you find that you are slipping into a pattern of using medication more and more frequently, this may indicate the need for a headache preventative medication. Only about 10% of those who would benefit from preventive medications are on an effective regimen. If you are already on a medication for prevention, and you are still taking lots of painkillers, you should work with your doctor. Be certain your prevention medication is as effective as it could be—there are many preventive medications.

Your doctor can help you to decrease your pain medications to make certain you are not in danger of developing medication overuse headache. A recent large population-based study of chronic headache sufferers (Bigal et al, 2008) found that barbiturate-containing medications, such as butalbital, and opioid painkillers were the most likely to cause a transformation from episodic migraine to chronic headache.  The prevalence of transformed migraine was 2.5%, and that due to medication was found to be 1.5%. (Some people "transform" from episodic to chronic migraine spontaneously, and not due to medication use.) What was especially interesting in this study was that the number of headache days per month was an important risk factor for developing medication overuse headache.  The more headaches you have, ironically, the more susceptible you are to certain pain medications causing more headaches. 

Opiates and butalbital can cause the transformation of episodic migraine to chronic headache (more than 15 headache days per month). Triptans and nonsteroidal anti-inflammatory medications, however, do not cause this transformation from episodic to chronic migraine.  They only cause more headaches if you are already experiencing a high number of headache days per month.  The surprising finding of this study was that NSAIDs can be protective for those who have a low number of headache days per month. And finally, the study revealed that in general, women are more likely to experience transformed migraine.  Men, however, are at more risk for transformation due to opiate use, and men who already have chronic headache are more likely to develop medication overuse headache due to triptan usage.

Treatment Satisfaction

Is your migraine treatment as good as it could be? Migraine sufferers often think that they have tried everything that there is to try for their headaches. Your current treatment might be good as it can get. But are you sure? There are new medications being developed all the time.

What are reasonable expectations for the treatment of migraine? A reasonable expectation of migraine prevention would be to reduce headache frequency by half, and to reduce headache severity by about half. It is possible to become headache free, and many people with mild-to-moderate migraine can do so with medication and lifestyle changes. Unfortunately, this is not possible for everyone.  If you have been on a preventive medication for several months and you have not experienced at least a 25% reduction in severity, discuss this with your doctor. Often a dose adjustment can help, and if not, a medication change may be in order.

With an acute migraine medication—the kind you take when you first get an attack, you know, the kind you're supposed to take early—you should expect to obtain some degree of pain relief within the first hour.  You should be experiencing relief of associated migraine symptoms (like nausea or avoidance of light and sound) with significant pain reduction within two hours. Many people will be migraine-free within two hours. Adding an anti-inflammatory medication to your migraine medication may make it work better. If you develop nausea in the initial stages of your migraine, anti-nausea medication may be helpful also. Be sure to stay well hydrated. Work with your doctor, remember to treat attacks early, and stay ahead of your migraines.

1. Bigal, ME, Serrano, S, Buse, D, Scher, A, Stewart, WF, Lipton, RB, Acute Migraine Medications and Evolution From Episodic to Chronic Migraine: A Longitudinal Population-Based Study, Headache, 2008; 48(8):1157-1168