Migraine is a neurological condition that can cause a range of symptoms. During an attack, a person will typically experience severe head pain. Nausea, vomiting, and sensitivity to light and noise can also occur.

Migraine is the second leading cause of disability in the world. Medications can reduce the severity and intensity of migraine attacks and help prevent them.

In this article, Dr. Deena Kuruvilla answers some common questions about migraine treatments, including the different types and their effects, benefits, and risks.

Doctors may classify migraine as episodic or chronic, depending on the frequency of migraine attacks.

According to the International Classification of Headache Disorders, episodic migraine causes fewer than 15 headache days a month, whereas a person with chronic migraine will experience 15 or more headache days a month for more than 3 months.

The American Headache Society recommends offering preventive treatments to people with migraine who have four or more headache days each month or experience significant disability due to their symptoms.

Migraine preventive treatments aim to help by:

  • restoring the ability to function
  • lessening the use of as-needed treatments for acute episodes
  • reducing the number of pain days each month

Some migraine preventive treatments include:

  • calcitonin gene-related peptide antagonists, such as galcanezumab, erenumab, fremanezumab, eptinezumab, rimegepant, and atogepant
  • onabotulinum toxin A, which is specifically for chronic migraine
  • beta-blockers, such as metoprolol, propranolol, and timolol
  • angiotensin receptor blockers, including candesartan
  • antidepressants, such as nortriptyline, amitriptyline, and venlafaxine
  • antiepileptic medications, which include topiramate and valproic acid

As-needed or acute treatments can also be a vital part of a person’s migraine treatment regimen.

Having a multistep plan on hand when a migraine attack starts can help reduce disability from the attack and prevent migraine progression.

Many new medications are suitable for use when an attack strikes. These include:

  • nonsteroidal anti-inflammatory drugs
  • triptans, such as sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, naratriptan, and frovatriptan
  • ditans, such as lasmiditan
  • gepants, which include rimegepant and ubrogepant

Every treatment regimen must be individualized to be effective. Each person with migraine has a different medical history and different tolerances to medication. They will often respond differently to treatments, so what works for one person with migraine might not work for another person.

However, the most effective treatments are the evidence-based treatments above. Researchers have studied these comprehensively.

There are ways to optimize preventive and acute treatments to make sure that they work efficiently.

For preventive treatments, it is important to start at low dosages if possible and increase steadily to an optimal dosage. Once a person has found their optimal dosage, the treatment can take 6–8 weeks to start working. For this reason, it is important to stick with preventive treatments at optimal dosages to get the maximal benefit.

For acute treatment to work at its best, it is key to take the as-needed treatment at the very onset of the migraine attack.

Those who experience nausea or vomiting may find it helpful to complement as-needed treatment with an antinausea treatment.

Preventive treatments and as-needed, or acute, treatments differ in several ways.

With most preventive medications for migraine, people take them daily by mouth or monthly by injection.

The ultimate goal of prevention is to anticipate migraine attacks and prevent them from happening. Prevention aims to reduce the overall number of migraine days, lessen the severity of attacks, and limit disability related to attacks.

Migraine attacks can keep people from very important professional commitments, such as work events, or a special personal milestone, such as a wedding or graduation. With this in mind, an ideal migraine treatment plan should include both preventive and as-needed treatments.

Acute treatments aim to stop a migraine attack once it has started. They are available in the form of a tablet, injection, or nasal spray, and a person can combine them with antinausea medications.

There are a few ways to improve treatment responses. These include:

  • educating a person about their treatment before they start
  • sticking to a preventive treatment, as long as they do not experience side effects
  • layering preventive treatments, in some cases

People can also complement an effective medical treatment regimen with other therapies, such as:

Integrative medicine is a popular choice among people with migraine because the side effects tend to be tolerable compared with those of prescription medications. Some integrative options include:

Natural approaches such as these can really complement mainstream prescription medications.

It is important to consider coexisting medical conditions, such as:

  • high blood pressure
  • depression
  • anxiety

If a person has a coexisting medical condition, their doctor may choose to customize their preventive treatment based on the coexisting condition.

Anxiety is common among people with migraine. Doctors may prescribe these individuals an anxiety medication that also prevents migraine.

Lifestyle factors play a key role in migraine prevention. Sticking to a regular sleep schedule, maintaining a moderate body weight, and addressing any underlying mood changes that may exist can help prevent migraine.

Specific factors that can contribute to worsening migraine include:

  • hormonal changes
  • changes in barometric pressure
  • having obesity or overweight
  • using as-needed medications on more than 10–15 days of the month
  • sleep deprivation or sleeping too much
  • dehydration
  • artificial sweeteners
  • too much caffeine

Managing the factors that worsen a person’s attacks is typically the best way to prevent migraine.

The Food and Drug Administration (FDA) has approved five devices for the treatment of migraine. The downside of these devices is the cost. Insurance companies often do not cover them.

However, these devices have tolerable side effect profiles. The currently available options are:

  • external trigeminal nerve stimulation
  • remote electrical neuromodulation
  • transcutaneous vagus nerve stimulation
  • noninvasive multichannel brain neuromodulation system
  • single pulse transcranial magnetic stimulation

I typically recommend discussing the slow removal of medication after someone has been headache-free or close to headache-free — meaning 0–4 headache days monthly — for 4–6 months.

I have found that once people with migraine are stable on a regimen, many do not want to taper off medications due to the fear that migraine will return. It is vital that the individual and doctor make a decision together on how to proceed. Abruptly stopping some preventive medications can result in withdrawal and dangerous symptoms that could result in a visit to the emergency room.

Due to this, people should not suddenly stop taking antidepressants and antiepileptic medications.

Deena E. Kuruvilla, M.D., is a board certified neurologist, headache specialist and Director of the Westport Headache Institute. She has served as an assistant professor and associate program director for the Headache fellowship at the Yale School of Medicine. Dr. Kuruvilla’s research and clinical work has been widely featured in the press, including Prevention Magazine, Neurology Today, the Hartford Courant, and the Wall Street Journal.