Migraine Treatment

Management

Migraine or more specifically the tendency to have migraine events (whether headache or dizziness or other symptoms) can not be cured. This tendency is probably genetically determined. At different times in a patient’s life, this predisposition may be more prominent and also behave differently. For example, younger patients tend to have more intense headaches while older patients may have more dizziness. Migraine has to be managed with a combination of methods. Generally, migraine is managed by either preventative or abortive treatment. Preventative measures aim to, as the name suggests, prevent migraine before it starts. Abortive treatments aim to manage the migraine after the migraine episode has started. In some patients, the symptoms become very frequent and in these cases preventative treatments are appropriate.

Abortive Treatment

Typical migraine headaches can respond to the “usual” treatments e.g. paracetamol and/or ibuprofen particularly if taken early at the time of the onset of headache. These medications are labeled as abortive. Often the patient has to lie in a quiet dark room and rest for a few hours. Some patients benefit from special abortive drugs such as triptans. Codeine and caffeine are also used but can cause rebound headaches/symptoms if taken regularly and hence are not recommended for regular use. The aim is to abort or stop the migraine pain. Other symptoms which may occur at other times when no headache is present such as dizziness may fail to respond to the abortive medications usually used for migraine headaches such as paracetamol, ibuprofen, and triptans. Therefore preventative measures are the mainstay of treatment for these migraine-associated problems including dizziness. These include prophylactic medications (i.e. preventative medications.)

During an attack of dizziness Buccastem (Prochlorperazine) can be used (for further information on this medication click here). This has to be prescribed by a doctor. The tablet is placed under the lip/gum and is absorbed without swallowing. It reduces nausea although it may not stop the attack.

Preventative Treatment

Certain factors can reduce the threshold for migraine symptoms. i.e. certain things make the migraine more likely. These “trigger” factors include psychological/physical stress, hormone levels (e.g. menstrual cycle in women), lack of sleep, hunger, thirst, dietary factory (particularly lack of caffeine). This is not an exhaustive list and in some patient, rather strange things may act as triggers e.g. strawberries or citrus fruit. Lifestyle measures aim to deal with these factors.

Certain dietary supplements or medications are also able to modify how likely one is to develop a migraine symptom.

The factors which can be modified by the patient include lifestyle measures and exercise.

Lifestyle

Lifestyle measures which help improve migraine are varied. These essentially involve avoiding triggers. One of the commonest triggers is stress. This can be related to unusual work or family factors which may be temporary. Sometimes, however, problems may persist. If possible patients should try to take a 5-minute break every 2 hours while at work. Try to spend 5 minutes walking. Use a portable shiatsu machine to massage your neck. Pay attention to your posture, especially your neck while at work.
Codeine or codeine type of drugs can, if taken regularly over a prolonged period of time, cause a mild addiction which can lead to chronic migraine. It is advised that codeine or codeine type drugs be stopped completely. This may initially cause a deterioration in your symptoms but eventually, there will be an improvement.

Dietary factors include caffeine. This can be addictive in a similar way to codeine. Although taking caffeine does not necessarily cause a migraine, patients are often mildly addicted to caffeine. It is generally recommended that all caffeine intake is eliminated at least initially. This includes coffee, tea, and fizzy drinks containing caffeine. Decaffeinated drinks can be substituted although some patients may be sensitive to the chemicals in decaffeinated drinks. Later once your problem is under control the caffeine drinks can be reintroduced to see what effect they have. Other common dietary triggers include chocolate, cheese, alcohol, monosodium glutamate, and certain types of preservatives. More unusual foods which can trigger migraine include citrus, strawberries, and yeast for example in bread. You may need to analyze your diet carefully to determine if there are any specific foods that may be precipitating migraine/dizziness. If your problem is particularly severe you may consider adhering to a strict diet eliminating as many of these factors as possible. A book entitled “Heal Your Headache” by Dr. D Buchholz deals in great detail with dietary triggers of migraine and how to avoid them. This book can be purchased over the Internet (e.g. from Amazon) or you could ask your local bookshop to order this for you. Some patients claim that eliminating certain food types can help e.g. gluten/wheat, yeast, and dairy products. Reducing sugar and or artificial sweetener has helped some patients with migraine.

Other dietary approaches for reducing migraine include ketogenic and low-calorie diet, reducing omega-6 and increasing omega-3 fatty aside intake and weight reduction in those who are overweight (see here).

It is recommended you remain well hydrated. Research carried out for Meniere’s Disease (which is closely related to Migraine) showed drinking 35ml/kg water per day reduced attacks. This equates to nearly 2.5 liters per day for a 70 kg “average” man.

Lack of sleep or too much sleep can act as a trigger.

Other possible approaches include relaxation and meditation. There are many websites, books, and specialists who can help with this (e.g. the book: Full Catastrophe Living, Revised Edition: How to cope with stress, pain, and illness using mindfulness meditation). The aim of these is to learn relaxation and reduce adverse reactions to stress. A course on Mindful based stress reduction is available here.

Other potentially useful resources for managing stress are found here, here, and here.

Understanding your condition and/or psychological approach is also of benefit. The book “The Pain Survival Guide” by Dr. D Turk is a book mainly aimed at patients with chronic pain but many of the ideas and approaches can also be used to help with other symptoms of migraine including dizziness. A copy of the book is available here.

Mr. Rejali and Mercia Health have no link/relationship (commercial, financial or personal) with any of the resources/people/books/courses mentioned above. None are guaranteed to work.

Exercise

Generally, aerobic exercise (such as walking and running) is good for the feeling of well-being and can be helpful in migraine. It increases patients’ resilience to physical stress which can be helpful in work. In some patients with migraine, however, exercise or physical stress can act as a trigger to start headaches/dizziness. The approach here is to work out a level exercise that can be managed without acting as a trigger. For example, if you run a mile in 10 minutes and this makes you unwell for many hours or days then start by walking for 5 minutes. If this causes problems then walk very slowly for 2 minutes. This way you can work out what you can manage. Once you are comfortable then very slowly build up your level of exercise. On occasions, however (for example if you have been stressed for other reasons) a level of exercise previously well-tolerated may trigger an attack of migraine/dizziness. It is important therefore to be able to read your own body and consider other factors when deciding how much exercise to carry out. Generally, more frequent less intense exercise is better. In some patients, it may be easier to think of the body as having a battery that once flat needs time to recharge. Pushing yourself too far will cause problems. You need to know how far your battery will take you.

If you plan to carry out an unusual physical activity that will be quite physical and/or stressful you may opt to take some ibuprofen (assuming you do not have any contraindications to taking this medication such as gastric problems or severe asthma) before undertaking this activity. Ibuprofen can be purchased over-the-counter. This can’t be done too regularly as Ibuprofen can cause inflammation/damage to the lining of your stomach if taken too often but it can be helpful on the odd occasion. It may help prevent the triggering of the migraine process.

Specific balance exercises can be found here.

Dietary Supplements

Magnesium has been shown in some trials to reduce the recurrence of migraine.

Natural sources of magnesium include unrefined whole grains, spinach, nuts, legumes, and white potato. Some of these however can act as a migraine trigger in some patients. Alternatively, magnesium supplements can be obtained from supermarkets or online (e,g, Amazon). The usual dose is 400 mg once daily. Magnesium Glycinate is well tolerated. The magnesium needs to be taken for 1 month before any change would be noted. Side effects can include diarrhea. If this happens you may opt to reduce the dose, take calcium supplements that could counteract diarrhea or stop the Magnesium. Magnesium can interfere with the absorption of a medication called Gabapentin. Magnesium and Gabapentin must be taken at different times during the day. If you have kidney/renal failure then the Magnesium dose may build in the body can cause potentially serious problems. Do not take magnesium if you have renal/kidney failure. For further information click here.

Co-enzyme Q10 has also been shown to be of some benefit in some patients with Migraine. The usual dose is 100 mg 3 times a day. There are no common serious side effects. Rare side effects include loss of appetite, nausea, and diarrhea. Co-enzyme Q10 may interfere with some medications including Warfarin, anisindione, and dicumarol. If you are on any of these medications you must discuss this with your GP before taking Co-enzyme Q10. As with magnesium patients may need to take Co-enzyme Q10 for 3 months before they notice any effect. For further information click here.

Riboflavin (also known as Vitamine B2) has been used for the treatment of migraine. The dose has to be quite high i.e. 400mg/day. The normal requirement is 1.3 mg per day in an adult male. It can make the urine yellow/orange. Side effects are rare. These include diarrhea and passing large amounts of urine. For further information click here.

Polyunsaturated omega 3 fatty acids (OPFAϖ-3) have been shown in some trials to be useful for prophylaxis of migraine attacks.

Palmitoylethanolamide (PEA) has been shown in trials to help reduce pain caused by nerve entrapment (e.g. sciatica).

Vitamin D has been shown in trials to help reduce migraine.

Probiotics

There is conflicting evidence of the benefit of probiotics for migraine. The risks and side effects of treatment with probiotics are low and so if patients are not keen on more aggressive treatment such as anti-depressant class drug probiotic can be considered. One product with did show benefit is Bio-Kult by Protexin (see here). I have no affiliation with the manufacturer of this product nor do I benefit from any sales.

Herbal treatments

Butterbur / Petastites. Butterbur is a plant. It contains various chemicals. Some of these chemicals can help prevent migraine. These include petasine and isopetasine. The plant also contains very dangerous toxins (pyrrolizidine alkaloids) which can damage the liver.

Although certain preparation (e.g. Petadolex) have claimed to have removed the harmful chemicals, there has been some reported cases of liver damage after taking this preparation. There is even more safety concern regarding other preparations and unbranded extracts.

At present, in view of this safety concern, preparations of Butterbur may not be safe.

For a full review please see here.

Preventative Medication

As mentioned above abortive medications such as paracetamol and ibuprofen are generally not successful at improving dizziness in migraine. The medications which are more successful in treating dizziness related to migraine are preventative migraine medications that need to be taken every day. These include medications that were often originally used for other conditions such as depression or high blood pressure. Many patients with migraine are quite sensitive to medications and the usual starting dose may need to be smaller than usual. All medications have potential side effect and this need to be measured against the potential benefit. The medication below will need to be prescribed by your doctor. Some have potential interaction with other medications. With respect to the treatment of migraine, all of the medications below are used off-license. This means the original license for use did not list migraine as a target disease. Nevertheless, if there are no suitable licensed medications, off-license medications can and are often used for the prevention of migraine.

Amitriptyline

This is an antidepressant class of drug. It is fairly effective for migraine. Common side effects include dryness of the mouth and occasionally tiredness or lethargy. It is best taken in the evening/night time. It is usual to start at a low dose such as 10 mg (milligrams) or even 5mg and the dose increased slowly e.g. by 5 to 10 mg every 2 to 3 weeks. If the dose has reached 50 mg and there has been no benefit it is unlikely it will be beneficial. The dose can be increased to 75 mg if required. It is a drug that is not recommended for use in patients with heart problems such as irregular heartbeat. It can also cause problems with passing urine or can on rare occasions precipitate glaucoma (pain in the eye, red eye, and blurred vision). Some patients may experience suicidal ideas. The drug is not recommended if there is a history of suicidal thoughts. Nortriptyline is a drug that is better tolerated but has similar actions to amitriptyline. The starting dose is the same but the eventual effective dose may be higher (up to 100 mg once a day). For further information click here.

Propranolol

This is a type of beta-blocker. Its traditional use has been as a blood pressure-lowering agent. Side effects include lethargy, dizziness when standing up due to low blood pressure. It is not recommended for use in people with asthma, depression, or diabetes. The usual starting dose is 40 mg twice a day or if not tolerated well to start at 20 mg twice a day. Eventually, a slow-release formulation can be used such as 80 mg once a day. For further information click here.

Verapamil

This is a medication that is used for an irregular heartbeat. Its side effects are generally mild including swelling of the ankle or constipation. It is not advised to take this medication while taking beta-blockers such as propranolol. The usual dose is 120 mg sustained-release formulation once a day. This can be increased to 240 mg a day. For further information click here.

Venlafaxine

This is also an antidepressant class drug. It has less sedating side effects than amitriptyline. The usual starting dose is half a 37.5 mg sustained-release tablet once a day for one week and followed by a whole tablet. Some patients may experience suicidal ideas. The drug is not recommended if there is a history of suicidal thoughts. The dose can be increased further if necessary. For further information click here.

Topiramate

This was originally used as an anti-epileptic (anti-convulsant / anti-seizure) medication. This medication seems to reduce irritability and sensitivity of nervous tissue. It is still used as an anti-epileptic medication. It is also used as a migraine preventative medication. The starting dose is usually 25 or 50 mg at night and this is increased in steps to 50 mg twice a day. Generally, it is well tolerated. Side effects include cognitive difficulty (difficulty thinking), pins and needles (paraesthesia), kidney stones, or visual problems. Some patients can lose weight. If taken for a prolonged period it would be a good idea to have your blood acid/base levels monitored by your doctor. For further information click here.

Cinnarizine

This can be obtained over the counter (e.g Stugeron) and has been shown to be effective as both an anti-migraine and anti-vertigo medication. Long-term use can have extrapyramidal side effects such as “Parkinson’s disease type shaking”.

Flunarizine

Used in many countries but not licensed in the UK. It has similar properties to Cinnarizine above.

Interventional treatments and Surgery

Some patients may benefit from a local anesthetic injection/block, botulinum (Botox®) injection, or surgery.

Electric Stimulation Treatment

Electric treatment has been shown to benefit some patients with migraine. It is not proven that this type of treatment is significantly better than placebo but it is a treatment method that does not involve medication which some patients prefer. See here and here for examples of devices.

Disclaimer

Mr. Rejali and Mercia Health have no link/relationship (commercial, financial or personal) with any of the resources/people/books/courses/manufacturer of medications/supplements mentioned above. None are guaranteed to work.