Taking the headache out of migraine management

Migraine headache is a recurrent, disabling neurologic condition that affects about one in six people in the United States. It’s twice as common in women than men and is more likely to affect people between the ages of 18 and 59. These are years of great potential work productivity, and uncontrolled migraine is therefore associated with high costs due to both absenteeism and presenteeism (lacking the ability to perform at one’s full potential). Many migraines respond well to treatment. Studies of people with migraines in the U.S., however, show that access to care and receiving the correct diagnosis are both barriers to adequate treatment.

Migraine is characterized by pounding or throbbing pain, often on one side of the head. The pain is severe and worsens with activity, and people with migraine often prefer to lie down when they have a headache. The headache is often accompanied by sensitivity to light and sound and sometimes nausea and vomiting. However, not every person with migraine experiences all of these characteristics. Many people with migraine have steady, pressure-like headaches on both sides of the head, but if the headache is severe and worsens with activity, the correct diagnosis is still migraine. About a quarter of people with migraine experience migraine with visual aura, sometimes called “ocular migraine.” This type of aura is a visual phenomenon that typically occurs before a migraine headache, lasts 5-60 minutes, and often has a spreading or progressive quality. Migraine aura can take many forms, but is often a C-shaped jagged line, sometimes with kaleidoscope patterns, blind spots, flashes or other shapes or colors in the field of vision.

Migraine is often misdiagnosed as another headache type. A very common diagnostic error in primary care settings is a patient receiving a diagnosis of tension-type headache when it should be migraine. "Tension-type headaches" are typically less severe, not worse with activity or exercise, and are not accompanied by sensitivity to light or sound or nausea/vomiting. Tension-type headaches typically respond very well to over-the-counter treatments such as ibuprofen or acetaminophen, and they are very rarely disabling.

“Sinus headache” is another headache type for which the correct diagnosis is often migraine. A study showed that over 80 percent of people who self diagnosed with sinus headache actually had migraine according to classification criteria. People who say they have “sick headaches” often turn out to have migraine as well. In short, if a headache is recurrent and disabling, it is reasonable to think that it might be migraine.

Receiving the correct diagnosis is important, as many treatments that are effective for migraine are not commonly offered to people with other headache types. For example, triptans were specifically developed for the acute (also called abortive or symptomatic) treatment of migraine and can be very effective. These medications, listed in the figure, should be taken as early as possible in the migraine attack. For this reason, people with migraine should be encouraged to have their medication with them at all times. Some people with migraine find that over-the-counter treatments such as nonsteroidal anti-inflammatory drugs (NSAIDs) are sufficient, but these still work best when taken early. Management of nausea is also essential when present. Nausea is often a larger contributor to migraine-related disability than the pain itself.

A subset of people with migraine should be offered preventive therapy. People with disabling headaches more than once a week or who do not respond well to acute treatment should be considered for prevention. Commonly used preventive therapies are listed in the Figure. Of these, propranolol and topiramate are approved by the FDA for migraine prevention and the rest are used off-label. Preventive medications should be taken every day, whether a headache is present or not, and a trial of treatment should be at least two months at the target dose. It is common to start at a low dose and increase until benefit is seen. Like all medications, migraine preventive agents can have bothersome side effects. The goal is to find a preventive that is effective for the patient without a significant burden of adverse effects. Trial and error is a normal part of the process of finding the right preventive for a patient, and it should not be expected that the first trial will always be successful. The goal when starting prevention is a 50 percent or greater reduction in headache frequency and headache-related disability.

Onabotulinum toxin A (Botox) is FDA approved for the prevention of chronic migraine. Chronic migraine is diagnosed when a person has headaches more than 15 days a month and they are migrainous at least eight days a month. Botox treatments are given in 31 injections sites in the head and neck and are administered every 12 weeks indefinitely. Insurance companies often require patients to have tried several preventive medications prior to approving coverage of Botox.

Even with optimal management, most people with migraines will experience an occasional breakthrough headache. Between headaches, some people with migraine (particularly chronic migraine) remain sensitive to light or sound. Accommodations, such as environmental modifications or breaks to allow medications to take effect, can be an important part of the treatment plan for these migraineurs.

A treatment plan that starts with the right diagnosis and includes effective acute treatment, preventive treatment when warranted and allowances for the occasional breakthrough when needed, can dramatically reduce migraine-related disability and improve work productivity.