New Medications Can Help Prevent and Stop Migraine Headaches

Historically, migraine headaches have been a real pain, even for doctors. There’s no imaging test that can detect a migraine like a CT scan shows a stroke or an echocardiogram lets you see the heart. Instead, migraine is diagnosed based on clinical criteria. For many years, there weren’t many effective treatments for migraine, either.

Today, there are many safe, effective treatments available. These days, hearing “you have migraine” is actually good news given how many excellent therapies exist.

About 11-14% of women and 5-7% of men in the U.S. have migraine attacks. These are moderate to severe, usually throbbing, headaches. Other common symptoms of migraine include sensitivity to light or sound, lack of appetite, dizziness, numbness in the arms or face and fatigue.

The brain develops “pathways” that can make the route to a headache easier to travel, and episodic (infrequent) migraine attacks naturally progress to chronic (15 or more per month) once these paths develop. That’s why it’s important to find a treatment method that completely resolves your migraine.

If you have the classic symptoms of migraine, you don’t need to suffer. And if you’ve tried older migraine medications that didn’t work, it may be time to try again.

While migraine is still diagnosed clinically, effective new medications mean doctors have a lot more tools in our toolbox, so we’re confident we can help.

The Old Way for Migraine Relief

If headaches are having a significant negative impact on your quality of life, talk with your doctor. Of course, “significant impact” is different for everyone, so I recommend the following: if you have anything more than three mild headaches per month, or if those headaches don’t go away completely when you take something like Tylenol, talk to your doctor.

In the past, doctors would look for an opportunity to treat two conditions with one medication. For example, if you had migraine and high blood pressure we might choose a blood pressure medication that also happens to help people have fewer migraine attacks—we did our best with the off-label options available.

Some examples of those “off-label” drugs include:

Antidepressants
Anticonvulsants
Antihypertensives

These medications can work fairly well, offering some people improvement in migraine frequency. But they don’t work for everyone, and they can have unwanted side effects such as sedation, weight gain, depression, kidney stones, liver damage, etc.

Adjusting lifestyle factors can help. I recommend a magnesium supplement to my patients, because almost all people with migraine don’t have enough. I also encourage them to monitor and adjust four important lifestyle factors that influence migraine: Stress, sleep, food, and water. But taking magnesium and getting a good night’s sleep aren’t always enough. New medications can help.

Three New Types of Migraine Medications

New prescription medications developed in the last 10 years have changed the game for people with migraine and their doctors.

Calcitonin gene-related peptide (CGRP) was discovered in the 1980s, when scientists thought this amino acid chain was responsible for making blood vessels dilate and processing pain.

Studies have shown that CGRP levels in the blood spike just before a migraine and infusing these peptides into the blood of migraine sufferers triggers a severe headache. Now we know that disrupting the work of CGRP can stop and even prevent migraine, and this is central to many of the new medications we now use.

1. Medications to Prevent Migraine

One of the exciting new ways to prevent migraine attacks before they happen are monoclonal antibodies that target CGRP. These lab-made proteins block CGRP or its receptors, stopping them from activating pain signals that are central to migraine.

Monoclonal antibodies are administered via injection either monthly at home by the patient or every three months via IV at an infusion clinic. These medications have been shown to result in up to about 50% fewer days with migraine with minimal side effects and no known drug interactions. Examples of FDA-approved CGRP monoclonal antibodies include Aimovig, Ajovy and Emgality.

If you don’t like needles, oral medications (pills) are also an option to prevent migraine. These medications contain a small molecule from a family known as gepants that can insert themselves into CGRP receptors, preventing migraine like gum in a lock. Qulipta is exclusively a preventative and Nurtec can be used as prevention or rescue. Their convenient tablet form means gepants work quickly, and they have a lower risk of side effects than the oral non-specifics we used to use. Gepants can also be used to stop a migraine when it happens.

2. Rescue Medications to Stop Migraine

Preventative medications can work well but do not eliminate all migraine attacks for everyone. That’s why I prescribe many of my patients a rescue drug in case of an acute migraine attack.

When a patient experiences a migraine, they can take a gepant to help. Within two hours, these drugs gum up the CGRP receptors, stopping a migraine in its tracks. Ubrelvy and Nurtec are approved as oral gepant rescue medications. The quickest is called Zavzpret. It’s delivered as a nasal spray and can start working in as little as 15 minutes.

Gepants are attractive in part because of their excellent safety profile. Because they generally don’t cause blood vessels to contract, gepants are safe for patients with cardiovascular risks such as high cholesterol, high blood pressure, or a history of smoking. In the past, patients with these risks and migraine had few options. Now, drugs like Ubrelvy, Nurtec OCT, and Zavzpret are helping many people find relief.

I expect gepants will soon become the standard of care for migraine treatment. Someday, they may even be available without a prescription.

3. Botox for Migraine Prevention

You’ve probably heard of Botox, a cosmetic injection to reduce wrinkles. But did you know Botox is a very effective treatment for migraine too? A drug made from a natural toxin called botulinum, Botox blocks release of CGRP and other neuropeptides that cause migraine.

For migraine, the toxin is administered with 31 small injections in specific muscles in the head and neck. The procedure takes about four minutes in my clinic and is repeated every three months. Some people notice improvement right away, but for others it can take two or three sessions to experience migraine relief.

Many patients with complex, difficult-to-treat migraine benefit from a combination of these treatments. Often, I prescribe a rescue drug in addition to preventative medication and Botox treatments and my patients see excellent results.

Making a Difference for Patients with Migraine

I encourage students and trainees to consider specializing in headache medicine, because there’s never been a better time when we’ve been able to provide more relief to more people. Today we have the tools to make a real difference for people, many of whom have been suffering for years or decades.

Often, my patients come see me between the ages of 35 and 45, which is when migraine attacks tend to get worse. Many tell me they’ve been getting along with over-the-counter pain medications. Often their headaches knock them down for the day, meaning they’re forced to miss work and head to a dark room to wait for the pain to pass.

If this sounds familiar, you don’t need to tough it out. Talk to your doctor about migraine headaches. Together, we can help develop a treatment plan that works for you.