Headaches & Migraines

Headaches

Headaches are just about the most common ailment imaginable. They’re also one of the most aggravating. They often crop up when they’re least welcome: during busy times at work; when you’re trying to sleep; even when you’re having sex (yes, sometimes this is not just an excuse!).

Yet although headaches are incredibly common, they remain somewhat mysterious. According to Joel Saper, MD, the director of the Michigan Head Pain and Neurological Institute, there are more than 300 causes for head pain. Three hundred! That can make it very difficult to determine specific triggers for individual people.

Some headaches are set off by certain foods or drinks. Dr. Saper reported that one of his patients was overjoyed when he discovered that the source of his chronic headaches was the glass of milk he had each night before bed. When he stopped drinking his nightly soporific, his headaches stopped.

Other headaches can be caused by a deficiency in a vitamin or enzyme that the body needs, like magnesium. Or by a deficiency in something the body has simply gotten used to having regularly, like caffeine. And, somewhat incredibly, still other headaches can be caused by the pills people take to get rid of the pain from their headaches!

The source of the sensation of pain from headaches is almost as elusive as their cause. Even though the pain is in your head, the brain itself doesn’t feel pain, according to Dr. Saper. (Otherwise, neurosurgeons wouldn’t be able to perform surgery with wide-awake patients, as they often do.) The head pain we experience may come from the scalp, skull, covering of the brain, sinuses, optic nerves, or muscles and nerves in the neck.

Headaches can also be caused by a serious underlying condition. Occasional mild headaches shouldn’t be a cause for concern. But severe or chronic headaches should always be evaluated by a physician.

Headaches rank very high on the list of reasons people see their doctors. Roughly 45 million people experience chronic head pain—and that doesn’t include those of us who suffer minor headaches occasionally. Some individuals suffer intense daily headaches. Diagnosing the cause of this kind of head pain can be incredibly challenging.

Celiac Headaches

Q. I suffered from migraine headaches for more than 10 years. I saw several neurologists, but my intense headaches forced me to take early retirement.

In the fall of 2002, I went from 3 headaches a week to almost non-stop. That November, I had only 3 days without headaches. I took migraine meds like Frova, Maxalt and Imitrex, but I mostly lay in bed in a dark room.

I was at my wit’s end. Then my family doctor suggested a gluten-free diet. Gradually my headaches became less frequent, and after several months I was 98 percent headache-free.

I feel I was given a new life! Please share my story so others can benefit.

A. Migraine is not often recognized as a symptom of celiac disease, but we have heard from others like you who suffered until they eliminated gluten from their diets. Celiac is more common than many physicians realize.

In this condition, sensitivity to gluten (a protein found in wheat, barley and rye) can result in symptoms such as fatigue, anemia, nerve pain, memory loss, osteoporosis, infertility, flatulence, diarrhea and digestive tract distress.

Headaches & Caffeine

Q. I am a healthy person and rarely take any medicine. I quit smoking 14 months ago and am trying to stop drinking coffee. Lately I’ve had trouble with fatigue and tension headaches in the afternoon. If I take Extra Strength Excedrin with a Coke on my break, the headache goes away like magic. Regular aspirin doesn’t work as well. Why is Excedrin more effective?

A. Each Extra Strength Excedrin contains aspirin (250 mg), acetaminophen (250 mg), and 65 mg of caffeine. That means that a standard two-caplet dose will provide you with 130 mg of caffeine. Together with your Coke, this probably provides as much caffeine as two mugs of coffee.

It is conceivable that your afternoon slump and headaches are due to caffeine withdrawal. People who customarily drink as little as 2 1/2 cups of coffee can experience symptoms such as lethargy, headache, and anxiety when they stop.

By taking a pain reliever that contains caffeine, you could be easing your withdrawal. An alternate solution is to try to reduce your caffeine intake gradually until you are completely weaned.

According to Dr. Joel Saper, a little caffeine every so often can be therapeutic for headaches. It’s when caffeine is taken daily in moderate or high doses that we become physiologically dependent on it, and then getting too much or stopping too suddenly can produce headaches.

“A friend had a headache that would not go away. I told her to rub a dab of Vicks on her forehead. She thought I was nuts, but it worked. She has been using it ever since.”

Medication Overuse Headache:

Too often, patients try to “treat” their headache pain themselves, by taking aspirin or acetaminophen to make the pain go away. This is fine if it’s just once in awhile, but if headaches occur several times a week, then taking overthe-counter analgesics can actually make things worse by triggering a vicious cycle: what doctors now call a “medication overuse headache.”

This is because frequent use of the analgesics meant to fight headache pain causes irritation of brain receptors. When these receptors become sensitized, which is what happens when they’re exposed over and over to analgesics, they’re more likely to trigger headaches. Thus, more frequent use of painkillers leads to more sensitization, which in turn leads to more headaches. Which can be maddening.

It can take weeks or even months of regular use for this vicious-cycle process to occur, but when it does, it can be difficult to get out of it again. Moreover, when patients are in this cycle, other treatments that may be appropriate for them won’t work. Under the guidance of her physician, the headache sufferer must stop taking the medication she’s been overusing, go through an adjustment period, and then she’ll be able to respond again to therapeutic treatments.

Often headaches will decrease in frequency simply when the frequency of medication use is decreased. Dr. Saper told us an extraordinary story about one of his patients who was hospitalized— and in fact at risk of dying—because for a long time, he had been taking 55 Excedrin per day! When he was carefully taken off of the Excedrin in the hospital, his headaches almost completely vanished, and 25 years later, he hardly ever has them.

Unfortunately, many doctors don’t know that chronic use (or abuse) of painkillers can lead to chronic headaches.

Describing the Headache Can be Challenging:

Physicians’ difficulties diagnosing and treating headaches stem in part from the fact that headaches can be caused by so many different things. As a first step, it may be useful for you to keep a headache diary: a careful record of the headaches you get; when they occur; what type of headaches they are (“ice-pick” or “jabs and jolts,” cluster, or other migraine-type headache; caffeine-withdrawal headache, etc.); any foods or other things you’ve recently consumed; any changes in your exercise regimen or sleep cycle, etc. This information may help your doctor diagnose and treat your head pain.

Recording when and how headaches occur may also help you and your doctor identify other underlying conditions you might have. For instance, those with celiac disease frequently get headaches when they eat gluten. When they remove gluten from their diets, they can have a dramatic reduction in headaches.

Estrogen can also be an aggravating influence for women prone to headaches, particularly migraines. It’s not at all uncommon for women to stop getting migraines after menopause—but by that same token, the migraines may very well start up again in women who go on hormone replacement therapy. And many women also discover that their headaches increase or worsen when they begin taking birth control pills.

The potential causes of headaches are too numerous and varied to cover exhaustively here, which is why keeping a headache diary that you share with your doctor could be helpful. But there are a number of common types of headaches that may be easier to diagnose and therefore treat than others. Again, serious or recurring headaches should always be brought to your doctor’s attention.

Caffeine Withdrawal Headache

Most people know that caffeine can be addictive. But not everyone is aware that stopping caffeine cold turkey—even just for the weekend—can cause a nasty withdrawal headache. The short-term solution is simple: consume some caffeine. But over the long term, it may make sense to cut your caffeine consumption so that you can take occasional breaks without suffering.

Dehydration and Heatstroke

In the summer months, another common cause of headaches is dehydration, and again, the solution is fairly simple: drink some water. But overheating should not be taken lightly. In severe cases, it can lead to brain damage or death.

Heatstroke (not to be confused with heat exhaustion, which is somewhat less serious) happens when core body temperature rises dangerously high and the heat can’t dissipate. In someone suffering from heatstroke, the body temperature will be high, and the skin is usually dry and flushed (not clammy and pale, as generally happens with heat exhaustion). Heatstroke often occurs after strenuous outdoor exercise, but there are also many medications that can make a person more vulnerable to it. It can come on very suddenly, and one possible symptom is headache, along with disorientation, weakness, and potentially loss of consciousness.

Heatstroke is a medical emergency, and one example among many that a headache can signal a very serious medical condition.

Tension Headaches

People often refer to headaches that aren’t migraines as “tension headaches.” It can be hard for non-specialists to determine what exactly constitutes a headache vs. a migraine, but as a general rule, if your headache responds well to over-the-counter treatment, and so long as it doesn’t occur more than once a week, it’s reasonable to tackle it yourself with an OTC painkiller, no matter what you call it.

There’s no best OTC option: aspirin, acetaminophen, and nonsteroidal antiinflammatories (NSAIDs), like ibuprofen, all work differently for different people. A little caffeine may help boost the headacheeasing power of your painkiller, and many headache pills and remedies contain it. (Excedrin, for example, and “Excedrin Migraine”—which is basically the same thing as Excedrin.) Or you can take your preferred OTC pill with tea or coffee.

A few alternative headache remedies we’ve heard about include a dab of peppermint oil on the forehead, or a smidgen of Vicks VapoRub on the temples.

Migraines

Migraine Triggers

• Alcohol
• Aspartame
• Caffeine withdrawal
• Chocolate
• MSG
• Nitrates
• Sulfites
• Tyramine

“Ice-Pick” Headaches

An “ice-pick” headache, now referred to by specialists as “jabs and jolts,” is one of the more painful sensations there is, and it’s very common in people who have a tendency to get migraine and cluster headaches.

It’s caused by misfirings of the nerves that come out of the brain and that then trigger lightning-like shocks of pain.

Jabs and jolts are not dangerous in and of themselves, and they can be treated with many of the same preventitive drugs used to treat migraine: beta blockers, antidepressants, and anticonvulsants. Occasionally, doctors will adjust the dose and mix a few drugs together in combination. NSAIDs can also sometimes be helpful.

Common Mistakes

According to Dr. Saper, there are some common mistakes both doctors and patients make when it comes to patients’ headaches.

By Doctors: In trying to manage patients’ pain, they may actually be making things worse if they allow patients to take painkillers or other medications too regularly.

By Patients: Overlooking headache pain for too long can be very serious. Patients also can make the mistake of abusing their bodies by smoking, drinking too much alcohol, or engaging in other behaviors that may make headaches worse.

A whole lot of people suffer from migraine headaches: roughly 28 to 30 million, according to the experts. Women make up the vast majority of those who experience them.

A migraine is a brain disorder, which Dr. Saper has referred to as a “physiological cascade of biochemical events.” As we’ve already mentioned, figuring out whether a headache is a migraine or some other kind of head pain is for a headache specialist to determine. But there are specific features of many migraines that often help distinguish them from other kinds of headaches.

Some people experience a “prodrome,” or a strange sensation that arrives before the onset of a migraine. Some others may see auras of flashing lights or spots, or they may simply experience an extreme sensitivity to light. They might also have a very strong sensitivity to sound. And still others become very nauseated, a feeling that can be aggravated by certain smells. Other symptoms that tend to differentiate migraines are headaches that are on just one side of the head, or head pain that throbs, particularly when the headache sufferer moves.

One reason migraines sometimes aren’t diagnosed right away is that we usually imagine them to be incapacitating. And they can of course be excruciating—but they aren’t always. If you think you may suffer from migraine, it’s worth going to a headache specialist for a diagnosis, because there are many treatments available for dealing with them. If OTC pain relievers aren’t working, migraine medicine might very well be more effective for you.

Triggers

If it turns out that you do, indeed, suffer from migraines, the next step is figuring out which substances tend to kick-start the brain cascade that leads to your headaches so that you can try to avoid them.

People have reported all kinds of triggers for their migraines, including (but certainly not limited to): alcohol (particularly red wine); aspartame (found in lots of sugar-free foods); caffeine withdrawal; chocolate; monosodium glutamate, or MSG (found in lots of processed foods, like potato chips, flavored nuts, etc.); nitrates and sulfites (found in processed meats, like salami and hot dogs); and tyramine (found in aged cheeses like gouda or cheddar, chocolate, nuts, sour cream, and yogurt).

These are just the food-and-drink triggers that we hear about most commonly, but again, according to Dr. Saper, there are over 300 different causes for headaches, and some people find that different substances, like sugar or milk, might be what stimulates a chemical cascade and precipitates a migraine for them.

There are also other things that might set people’s brains off, like second-hand smoke, perfume, irregular eating patterns and especially skipped meals, dehydration, or insomnia. A headache diary is a useful place to start for diagnosing your triggers. It’s also helpful to know that brains prone to migraine like to stick to routine, so when they get off of that routine, they may run into trouble.

Of course not everyone agrees about what constitutes a migraine trigger. The makers of aspartame, for example, are very quick to point to their data showing that aspartame does not lead to migraines. And one of our readers asked us about a purported migraine trigger that many people are loath to give up. He wrote: “My wife loves chocolate, but she read that it can trigger headaches. Now she won’t eat it, even on special occasions. I used to buy her great chocolate for Valentine’s Day and her birthday and she really enjoyed it. I never remember her getting a headache right after eating chocolate, but she does occasionally suffer from migraines. Can you tell me why chocolate is a problem?”

If you’re anything like us, you will no doubt be relieved to hear that there has been at least one double-blind study demonstrating that chocolate was not more likely to produce headaches than placebo (in this case, carob). Phew!

That isn’t to say that no one will ever experience headaches after eating chocolate—that is what the headache diary is for: to help figure out your specific triggers—but there’s no reason to eschew this great life pleasure completely without first determining if it is troublesome for you.

Nondrug Approaches

The advances that have been made with prescription medications for migraines over the past couple of decades have been quite remarkable. But for those who would rather try a non-drug approach first, there are also some natural remedies that have been showing promise for soothing headaches. Keep in mind if you are treating a migraine, the earlier you start with the treatment, the more likely you are to get relief.

Riboflavin

There has been some interesting research done to suggest that riboflavin (vitamin B2 ) may be able to reduce the frequency of migraines. A study in which 400 milligrams of riboflavin was administered daily showed that participants could expect a drop from 4 days of migraine a month to 2 days a month on average.

But 400 milligrams is a really high daily dose of riboflavin; another study suggested that as little as 25 mg per day might be enough to help decrease migraine incidence. And of course as with any other supplement or vitamin, you should always take it under the supervision of your physician.

Vitamin B Complex

“I’ve had migraines for many years. I think I’ve taken every migraine drug on the market and even ended up in the emergency room a few times.

“I was finally sent to a neurologist who told me to take vitamin B complex (B-100). I can honestly say I have not had a migraine headache in 2 years. I couldn’t believe after so much time taking drugs that all I needed to do was take a vitamin.”

Ginger

“The best thing I’ve found [for migraine] is ginger: Jamaican-style ginger beer is good, though rather sweet; the pickled ginger sold with sushi is a godsend. It also helps with the nausea.

“I sometimes make a tea of mint, chamomile, sassafras (which one grandmother called ‘headache bark’), some cinnamon sticks, cloves and a bit of valerian. I add grated fresh ginger when preparing the tea. It’s not a cure, but it helps, as does a warmed buckwheat-filled pack along my back and shoulders and ice packs on my temples and forehead.”

Feverfew

There are also several herbs that have been touted as headache salves. Feverfew (Tanacetum parthenium) was used as far back as ancient Greece for its healing properties. It lost its popularity during the 19th century, but lately it’s been staging a comeback, and there have been studies conducted to prove its efficacy for fighting headaches. Mostly, though, it’s used to stave off migraines rather than to treat those that have already hit.

Europeans and Canadians have so far embraced feverfew more ardently than we have in the United States. This might be because other countries’ governments are more rigorous about regulating herbal supplements and have set requirements on the minimum amount of the active ingredient (parthenolide) that must be contained in products purporting to include feverfew (0.2 percent in Canada, and 0.1 percent in France).

The herb is supposed to be taken every day for at least two months in order to prevent migraines.

The results of several double-blind, placebo-controlled studies of feverfew have been somewhat ambiguous. On the other hand, feverfew seems to be very safe, so giving it a try shouldn’t hurt you. We recommend trying one of the standardized products produced in another country, for example the OTC Canadian medicine Tanacet.

Pregnant women should avoid this herb, and it may interact with anticoagulants. Those who try it should taper off gradually to avoid any rebound effect of migraine onset or trouble sleeping. Some reported side effects include canker sores, mild stomach upset, and gas.

Butterbur

Another herb that has recently come back on the scene is butterbur (Petasites hybridus). Not many double-blind, placebocontrolled trials have been conducted on butterbur, but in those that have been done, it’s been shown to be useful for preventing migraines. It may also help children and adolescents avoid migraines, although the study that offered these findings was not placebo-controlled.

One thing to consider about butterbur is that the plant contains pyrrolizidine alkaloids, which are toxic to the liver. This has raised questions about the safety of taking butterbur long-term as a supplement. But the manufacturers of a patented butterbur root extract, Petadolex, reported that the process they use for extraction filters out the harmful pyrrolizidine alkaloids.

Still, we recommend that you consult your doctor before embarking on a longterm course of daily butterbur consumption, and we also think that it’s best to stick to a supplement that uses this type of supercritical carbon dioxide extraction.

MigreLief

We’ve had some readers swear by the OTC product MigreLief, which is a combination of riboflavin, feverfew, and magnesium. It’s available by phone at: (800) 758-8746, or at the website: www.migrelief.com.

Acupuncture

One non-drug approach that has been shown in several studies to be helpful not only for migraine prevention, but also to alleviate pain for migraines that have already come on full bore, is acupuncture. There was a big study conducted in the United Kingdom,in fact, that showed that people who used acupuncture took less pain medication and had fewer sick days home from work.

The strange thing is that in studies that used a “placebo” (a sham version of Chinese acupuncture), both the real acupuncture and the placebo groups benefited. And even more surprising, both of the groups benefited as much as people taking the standard preventive prescription drugs for migraine generally do. (It doesn’t work quite as well as Imitrex does, though.)

Acupuncture seems to be a safe option, and serious side effects are very rare. We of course recommend using a licensed practitioner, preferably one who has been trained in treating migraines.

One downside to acupuncture treatment is that it can be quite expensive, at $60 to $120 a session. Check with your insurance company to find out if it is covered under your plan.

Melatonin for Cluster Headaches

According to Dr. Saper, there has also been some interesting research done recently on melatonin for headaches, specifically of the cluster type, which are more common in men. (And at least one study, a large one in Brazil, indicated that 3 mg of melatonin daily was useful for preventing migraines not necessarily of the cluster type.)

The reason they’re called cluster headaches is that they appear in clusters, or cycles: they may not crop up for 6 to 18 months, but then several will occur over the course of a few days or weeks, increasing in frequency and severity. They can be absolutely debilitating for those who experience them.

The standard treatments are prednisone, a steroid, which is very effective but which carries all of the risks associated with taking any steroid regularly, and the calciumchannel blocker verapamil. It appears that cluster headaches are misfirings of the hypothalamus, the brain’s timing mechanism. Interestingly, melatonin is low in men who are prone to cluster headaches, and it is in fact even lower just before the onset of a cluster cycle. One of the newer treatments for cluster headaches is OTC melatonin supplements (CNS Drugs, Feb. 2020).

Apparently, electrodes used to stimulate the hypothalamus are also being tried as a new, experimental treatment for otherwise completely untreatable headaches.

Coenzyme Q10

Coenzyme Q10 has also been touted as a natural remedy for migraine relief that has relatively few side effects. One Swiss study indicated that 100 mg three times per day was better for migraines than placebo.

People taking the anticoagulant Coumadin (warfarin) should not try Co Q10, however, as the two may interact.

Magnesium

Magnesium has also been suggested as a useful therapy for migraine, and one that is safe enough for children to use. Magnesium is very important in the cascade of brain chemicals that can cause migraines, according to Dr. Saper, and some people who suffer from them may have a magnesium deficiency. Dr. Saper told us that they actually give magnesium intravenously to some people admitted to the hospital with severe headaches, and that it can dramatically turn headaches off on the first day of treatment.

Others include magnesium in a preventative strategy (Open Medicine, Nov. 23, 2022):

“Riboflavin (vitamin B2), coenzyme Q10 (CoQ10), magnesium, butterbur, feverfew, and omega-3 polyunsaturated fatty acids are among the dietary supplements suggested for the management of migraine.”

Tread lightly with supplementation, though: as anyone who has ever taken Milk of Magnesia for constipation knows, another effect that magnesium is famous for is helping the bowels move. Take too much, and they will most likely move more than you want them to!

The dose varies a lot from person to person (and of course would be much smaller for a child), but it may be useful in the 250-500 mg range. We suggest that you consult your doctor. Anyone with poor kidney function should be cautious about magnesium supplements. They require medical management.

Biofeedback

Biofeedback is a technique in which practitioners learn to warm their hands and fingers, and it may also be useful for treating migraines. It’s certainly quite safe, and it has been shown to be effective for children and teens.

Dr. Saper notes that lifestyle changes can produce dramatic physiological effects for some people: not only biofeedback, but meditation, exercise, and changes in diet may all be so efficacious for some headache sufferers that they no longer need to take much medication after making these other changes in their lives.

Brain Freeze

If you’ve ever experienced “brain freeze” from eating ice cream or drinking a slushie too fast, you know it can be painful. (Doctors call it “sphenopalatine neuralgia,” which is quite a mouthful in itself.) Nonetheless, some migraine sufferers tell us that deliberately provoking an ice cream headache at the outset of a migraine can sometimes stop it cold.

One reader discovered this benefit quite by accident:

“Holy cow! I can’t believe ice cream is a legitimate treatment for headaches.

“I just had three migraines right in a row and didn’t know how I was going to take care of my 3-month-old baby all day if the cycle kept going. I ate an ice cream bar and my migraine was gone almost instantly. I figured it was coincidental but I’m glad to see from your website that I’m not nuts!”

An ice cream headache usually doesn’t last long and is triggered by nerves in the palate sensing the intense cold from a frozen dessert or ice water (Headache, Jan. 1992). These clinicians found that such cold-stimulus headaches are actually less common in people prone to migraines and concluded, “the ice cream headache seems not to have any special significance for migraine patients.” We don’t think they got that right, though. While many people with migraine headaches find it impossible to trigger an ice-cream headache on demand, scores have told us that this helps avert a migraine if done at the first hint of such a headache. Scientists have found that a headache induced by a cold stimulus increases blood flow and reduces resistance in the middle cerebral arteries (Frontiers in Neurology, June 28, 2019). Those changes might be brought on by a reaction of the TRP channels in the nerves in the mouth. TRPM8 senses cold as well as menthol (Science, Jan. 12, 2018) and it has a role in migraines (Headache, Oct. 2016).

Max offers this possible explanation in a comment:

“Functional MRIs show that in the earliest stages of an oncoming migraine excessive electrical (pain) impulses generally pass through the spheno-palatine ganglion, a conjunction of nerves at the rear of the roof of the mouth. Often one can induce an “ice cream headache” using ice or ice cream which will disorgnize those impulses and divert the process that will soon lead to an migraine. No guarantees but neither is there any cost or any side effects.”

Ian R also has a lengthy explanation:

“I have been getting what are termed cluster headaches. They are a type of migraine that occur for about an hour up to several times a day, frequently for a period of time (the cluster) then seem to stop, just to occur later. (For me it was 2008 then 2011.) The pain is an incredible throbbing above my left temple.

“Sometimes cold water from the shower, just over my head could dial it back a drop, but the only way it ends is by my blood pressure dropping. This can occur naturally in 1-3 hrs but can be shortened with a little understanding of the way most migraines occur.
What is not clearly understood is the bidirectional relationship of our nervous system. This leads to the confusing myriad of symptoms, with seemingly one common factor. Cranial nerves are HUGE, and for me it is the Olfactory I nerve (left) that is triggering pain sensations.

“Simply, by using hot and cold beverages or food, stimulating the nerves in the roof of your mouth will likely affect your migraine. (Ice cream headaches are the same trigger, but when it is undesired.)

“DEPENDING ON THE MIGRAINE either hot or cold can just as easily exacerbate the migraine, so if you try ice-cream or coffee, start slow. Caffeine can cause blood vessels to expand, so the pressure is somewhat relieved. This helps almost everyone, and its why Excedrin can work. Coffee, chocolate ice-cream can be the best combination for some, while hot, green tea works for others.

“The benefit of this type of relief is that unlike medications like Imitrex, Calcium channel blockers, and Excedrin, the effects are actually more short-lived and limited. There isn’t going to be a distinct sedative effect (which any medication that lowers blood pressure will have). Being that you are mostly trying to heat or cool the roof of your mouth, consuming the food or drink isn’t even that critical. Holding the ice cream for example, in your mouth will cool the roof, and some of the caffeine will actually be absorbed by the blood vessels under your tongue. If you are on a diet, or are even lactose intolerant, and want to use the nearest store, don’t bother swallowing the ice-cream once it warms up a bit, just swap for a colder bite.”

Before embracing brain freeze as a solution for migraines, keep in mind that in certain cases a cold-stimulus headache could kick off atrial fibrillation (American Journal of Case Reports, Jan. 13, 2016).

Devices

Before we turn to medications, we should mention a couple of medical devices used to prevent migraine or cluster headache attacks. One hand-held device, called gammaCore Sapphire, is used for both prevention and treatment. It is designed to stimulate the vagus nerve, and the manufacturer promotes its use for hemicrania as well as migraine and cluster headache.

Another device, known as Cefaly, sticks to the forehead like a third eye. It has two settings, one for headache treatment and the other for prevention. Rather than the vagus nerve, Cefaly stimulates the trigeminal nerve. A Polish study found that use of this device reduced the number of migraine headaches by 50% (Neurologia | Neurochirurgia Polska, Mar-Apr. 2017).

Migraine Medications

It’s important to keep in mind that migraines are a serious brain disorder, and treatments of any kind, whether herbal or prescription, are never a substitute for medical care from a doctor who can diagnose, monitor, and treat your condition. You should always keep your doctor well-informed about any and all treatments that you are trying, including alternative headache therapies.

Luckily, doctors have many more treatment options at their disposal than they did just a couple of decades ago, and there have been considerable advances in headache medicines.

Because migraines are often preceded by a “prodrome,” or a funny sensation that a headache is on its way (this may be an aura, blinking lights, a tingling in fingers, a bit of nausea, etc.), many who suffer from migraines have a small window in which they can act to banish their headache before it brings them grinding to a halt. The optimal time to take any migraine medication is at the earliest possible sign of onset.

It is useful to know what your warning signals are, so to the degree that you can, pay attention to what triggers your body is sending to you that it’s about to be the victim of a nasty migraine.

Over-the-Counter Drugs

As we mentioned earlier, there are plenty of over-the-counter analgesics that may be effective even against some of the less debilitating migraines. Aspirin, ibuprofen and naproxen can all ease a mild to moderate attack (Headache, June 2015).

Most companies have developed a “migraine” formulation of their painkillers (i.e. Excedrin Migraine, Motrin Migraine Pain), and while this may be just a marketing gimmick, studies have shown that Excedrin Migraine (and therefore perhaps just regular Excedrin) is surprisingly effective at alleviating migraine pain and symptoms: it did better than ibuprofen in a head-to-head trial, and it even beat Imitrex (sumatriptan) in ameliorating head pain.

But an Excedrin may not be enough to stop a really brutal migraine in its tracks; for that, it may be wiser to turn to one of the powerful prescription medications developed for fighting migraines.

Triptans

Triptans represent a real revolution in migraine treatment. Developed over the past 20 or so years, this class of prescription medication is comprised of selective serotonin receptor agonists that can actually reverse the chemical changes in the brain that lead to a migraine when taken early enough. This generally stops headache pain dead in its tracks.

Sumatriptan was the first of the triptan medications to be developed, and it was initially taken as a self-administered injection. Soon, sumatriptan and other triptans were turned into pills that could be taken orally, but an injection might still be helpful for those who are so severely nauseated at the onset of a migraine that they are unable to keep a pill down.

Triptans are in many ways remarkable drugs that can significantly improve the quality of migraine sufferers’ lives. They have been compared in studies to the older prescription migraine medicine, Cafergot (ergotamine and caffeine), and they have performed admirably, acting more quickly and effectively to stop pain, and without inducing major side effects.

But they’re not for everyone. Some people have suffered from unexpected heart attacks while taking triptans, so you should absolutely tell your prescribing doctor everything about your medical history, including your potential risk for having a heart attack (i.e. you should let her know if you have diabetes, high blood pressure, high cholesterol, or any other relevant condition, or if there is a family history of heart attack or stroke). This is a rare reaction, but one that should obviously be taken quite seriously. Notify your doctor right away if you faint or experience chest pain, or pain in the jaw or left arm after taking a triptan.

Another downside of triptans is that they are extremely expensive. Some are available in generic form, but we have unfortunately become quite wary of generic drugs over recent years. Still, if the cost of triptans is prohibitively high for you, it may be worth at least experimenting with a generic. (Then again, we know how little migraine sufferers relish an experiment when it comes to pain.)

One tiny, unintended “benefit” of the high price of triptans is that they’re unlikely to be overused. There are also other prescription drugs if cost is an issue.

• Almotriptan (Axert)
• Eletriptan (Relpax)
• Frovatriptan (Frova)
• Naratriptan (Amerge, Naramig)
• Rizatriptan (Maxalt)
• Sumatriptan (Imitrex, Imigran)
• Zolmitriptan (Zomig)

Triptans work differently in different people. If you try one that doesn’t work for you, it may well be worth it to try some of the others until you find one that is successful. But this experimentation can be costly: many triptans are $15 to $20 per pill, which may or may not be covered by your insurance policy.

Ergots

Ergotamines, or ergots, are another prescription drug option for those who decide for cost or other reasons not to take triptans. They are in some ways similar to triptans, but they have a broader influence on brain receptors.

Ergotamines should not be taken by anyone who has a history of heart disease. In addition, they are also not appropriate for pregnant women, as they might trigger premature labor and fetal complications.

To learn more about medications for migraines, you may wish to listen to our recent podcast on the topic. It is Show 1294: New Treatments for Migraine Headaches.

Preventive Medications

New Migraine Medicines:

In the last few years the Food and Drug Administration has approved three new migraine medications: erenumab (Aimovig), fremanezumab (Ajovy) and galcanezumab (Emgality). An intravenous formulation, eptinezumab (Vyepti) is also available. The first thing you likely noticed is that the generic names are all virtually unpronounceable, except for the “mab” at the end of each drug. That’s because they are all monoclonal antibodies.

By now, most people are familiar with antibodies, especially in the time of the coronavirus. They are proteins generated by the immune system to inactivate bacteria and viruses. We won’t dig too deeply into the immune system here. Should you wish to learn more about antibodies, the best discussion can be found in our podcast with Matt Richtel. He describes in understandable language the intricacies of our immune system. His book, An Elegant Defense: The Extraordinary New Science of the Immune System: A Tale in Four Lives is magnificent!

Monoclonal antibodies (mAbs) are made in the laboratory thanks to genetic manipulation. These compounds are key to the biotech revolution going on within the pharmaceutical industry. These man-made antibodies have been used to treat cancer, rheumatoid arthritis, lupus, ulcerative colitis and multiple sclerosis, to name just a few of the many conditions these products treat. Now, we have mAbs against migraines.

All three of these new drugs target something called CGRP (calcitonin gene-related peptide). Scientists believe that when CGRP is released from cells in the brain, it causes blood vessel dilation, inflammation and pain. This cascade of events leads to migraines. Aimovig, Ajovy and Emgality prevent CGRP from doing its dirty work. They are prescribed to prevent migraine attacks. These are not “as needed” medications. In other words, you don’t inject such medicines after you are experiencing an attack. They are designed to be used prophylactically. And yes, you read correctly, they are injectables. That’s because many monoclohal antibodies have to be injected rather than taken orally.

One reader shared this story in 2019:

“About a year ago, I learned about a new migraine medicine called Aimovig. I asked my neurologist if he could prescribe it, since I was averaging nine major headaches and 18 days off work each month.

“At first, he was reluctant to prescribe Aimovig because it was so new. But all my other medications were barely working, so he finally agreed.

“This drug changed my life. I inject it every 28 days and now average just one headache a month. That means a lot less missed work and a lot less suffering. I have experienced no side effects, and I hope others can benefit as I have.”

All three drugs are self-injected roughly once a month. They are pricey! One auto-injector can cost anywhere from $600 to $800. That’s why insurance companies often approve such drugs only after other treatments have failed to control chronic migraine attacks. An overview of all three drugs offered the following effectiveness data (American Journal of Medicine, June, 2020).

“Erenumab [Aimovig] reduced monthly migraine days by 6.6 days compared with 4.2 days for placebo. Another study showed fremanezmab [Ajovy] reduced the mean migraine headache days for both FDA-approved dosages compared to placebo [about 6 days a month compared to 3.46 days]. Galcanezumab had a greater mean change in migraine headache days compared to placebo (4.2 vs -3.0 days, respectively).”

Side Effects of CGRP Injections

The most common side effects of these medications is soreness and/or redness at the injection site. Aimovig can also cause constipation, nausea and muscle cramps. It may lead to elevated blood pressure. Ajovy and Emgality may cause an itchy rash (or just itching) as well as hives. Some people suffer serious allergic reactions (anaphylaxis) to each of these medications. Because these medicines are all relatively new to the market, further side effects may be discovered in the coming years.

Some researchers hope that these injections might also help some people who suffer from cluster headaches. However, trials up to now have been inconclusive (Brain Sciences, Jan. 6, 2020).

Gepants

Another new type of migraine medication may be used to prevent frequently recurring migraines. This class of medications includes rimegepant (Nurtec ODT) as well as atogepant (Qulipta) and ubrogepant (Ubrelvy). However, Ubrelvy is for treating and not for preventing migraines. On the other hand, Qulipta is designed for prevention rather than treatment. Nurtec ODT does both. These medications are pills (or in the case of Nurtec, an orally disintegrating tablet).

Side effects of Qulipta may include nausea and loss of appetite. Weight loss, constipation, fatigue and liver enzyme elevations have also been reported. Some people taking Ubrelvy also report nausea, in addition to fatigue, sleepiness and dry mouth. The most common side effects of Nurtec ODT are nausea and stomach ache.

Topamax

There are oral drugs for migraine prevention that are taken daily rather than at the onset of an incipient migraine. Topiramate (Topamax) might be the most prominent.

Preventive medicine may be one option for someone who has such frequent migraines that she is taking medication two or more times a week, thus putting herself at risk for the vicious cycle of medication overuse headaches.

Topamax was first developed as an anticonvulsant medication, but it has also been approved by the FDA for migraine prevention.

In clinical trials, Topamax performed significantly better than placebo for both children and adult migraine sufferers, and it did about the same as other preventive migraine medications. On average, it cut migraine frequency in half, which means that those who took it got approximately two fewer migraines per month.

There are also some side effects that have been associated with Topamax, including tingling and numbness, confusion or mental fogginess, tiredness, and weight loss.

One rare but very serious side effect that can be caused by Topamax is a dangerous metabolic imbalance in which ammonia builds up to toxic levels in the body. Topamax can also lead to glaucoma or other vision problems.

As with any new medication, you should be sure to discuss all of the potential benefits and risks of Topamax with your doctor before filling your prescription.

Other Prescriptions for Prevention

If your doctor decides for some reason that Topamax isn’t right for you, there are other preventive medications available.

The anticonvulsant divalproex is also prescribed to ward off migraines. And doctors have frequently found beta-blockers useful for this purpose, too. The two that are prescribed most often are propranolol and atenolol. And as we have already mentioned, the calcium-channel blocker verapamil is also sometimes prescribed for migraine, particularly for cluster headaches.

Another medication that has been shown to be helpful for those who suffer from migraine and also have high blood pressure is olmesartan (Benicar), another blood pressure drug. Some of the people in a study of Benicar felt dizzy on the medicine, but it otherwise seemed to be quite well tolerated.

Other preventive drugs that your doctor may discuss with you include amitriptyline (Elavil), and a variety of other antidepressants.

You may be surprised to learn that Botox injections are another promising treatment that headache specialists have recently been trying with their patients. The double-blind studies that have been conducted on this therapy have been fairly promising, and it is certainly far less invasive and risky than another treatment that is sometimes used for migraine prevention: heart surgery. It’s not yet entirely clear who the best candidates for Botox injections might be, but it also seems to be tolerated well.

Headache specialists have fairly recently come to realize that inflammation plays a very big role in causing the brain cascades that lead to migraine, and so one other area of research that drug companies have been working on is developing medications that target the chemicals that cause inflammation in the brain.

That may help explain why a simple, inexpensive and old-fashioned medication, aspirin, taken daily (doses 81 mg, a single low-dose tablet, up to 325 mg, a single regular-strength tablet) appears to prevent recurrent migraine for many people (American Journal of Medicine, April 1, 2020). Even though you can buy aspirin without a prescription, anyone planning to take the drug every day, even at a low dose, should discuss the treatment with a doctor. Daily aspirin use could lead to digestive tract irritation that can be serious, so you should carefully weigh the benefits and the risks.

Another major innovation that has taken place in the treatment of headaches over the past several years is that there is now a Board Certification for Headache Specialists with two major national exams. Dr. Saper has told us that this change has really raised the standard of headache care.

Menstrual Migraines

Over the past several decades, researchers have contemplated why it is that women experience so many more migraines than men. One possible answer seems to be that migraines are frequently tied to menstrual cycles and changes in hormones. Both estrogen and progesterone affect the chemicals in the brain that can lead to the cascade that triggers a migraine.

Migraines are about twice as likely to strike during the first few days of a woman’s menstrual cycle than they are during the whole rest of her cycle. As if menstruation weren’t headache enough!

But one upshot is that, in this case, knowing is most certainly half the battle: being able to plan for a potential migraine means you’ll be much more likely to be able to head it off at the pass, as it were, with preventive measures. This means being sure to get enough sleep, stick to your routine (don’t skip coffee or tea if it’s part of your daily regimen, for example), avoid trigger foods and other substances, and not to over-exert.

There are also other things that you may want to consider giving a try. For one, many physicians recommend to women prone to menstrual migraines that they take a nonsteroidal anti-inflammatory (NSAID) like mefenamic acid (Ponstel) for a few days before the onset of their period, and then continuing on for a few days into menses. Other NSAIDs like naproxen (Aleve) or ibuprofen (Advil, Motrin) may also have some positive effect. Just be advised that all of these pain relievers can lead to stomach and GI tract upset, so be sure to take them with some food.

Doctors have also been experimenting with magnesium for women suffering from menstrual migraines, with some success. One study showed a decrease in pain and the number of headache days for women who took 360 mg of magnesium each day starting on day 15 of their cycle through the begin of menstruation. And another study showed some promise for daily supplementation with soy isoflavones.

There are also a few triptans that seem to provide relief from menstrual migraines. The longer-acting ones like Amerge, Frova, and Naramig may be able to stop an anticipated migraine. Oral contraceptives, especially the kind that limit the number of period days, may also help some women.

Sex Headaches

Not Tonight, Dear Sex Headaches are Serious

Sometimes when my husband and I make love I get an excruciating headache at climax. It lasts only a few minutes, but it is so painful I am nervous about having sex.

I asked my doctor, who said sex headaches are nothing to worry about. My husband is understanding but disappointed, and I can’t ask him to accept this situation indefinitely.

The doctor didn’t offer any solution. Is there something I could take to prevent these headaches?

Doctors call your condition HSA (headache associated with sexual activity). It requires a complete medical workup (CT scan, MRI, etc) by a neurologist to rule out any serious underlying problem.

Such headaches may consist of a dull pain that gradually worsens during sex. Another type more typically begins suddenly at the moment of orgasm. Three times more men than women report these headaches (Neurology, Sept. 2003).

Your doctor may consider prescribing preventative medication such as a beta-blocker (for example, atenolol or propranolol). Some physicians prescribe indomethacin or a similar anti-inflammatory pain reliever to be taken an hour beforehand to prevent HSA.

The idea of a “sex headache” may sound like the punch line to a bad joke. But in reality, they could be serious.

A sex headache can be one of two types: a headache that happens just before or during an orgasm that is often explosive and extremely painful. Or one that comes on more gradually, typically with a dull, throbbing ache in the back of the head.

If you experience a sex headache, it’s vital that you set up an appointment with your doctor right away and have a full work-up with imaging done such as a CT scan, or better yet, an MRI. Sex headaches can be caused by a few different things, and some of them require treatment in order to avoid serious consequences.

This point was hammered home to us by an emergency room doctor, who wrote in response to a letter we received several years ago from a woman experiencing sex headaches (see her letter in the sidebar at left). Here is what he wrote: “Several weeks ago you answered a question from a woman who suffered an excruciating headache whenever she had an orgasm. Although her neurologist had done a CT scan and told her nothing was wrong, as many as 20 percent of brain aneurysms don’t show up with such a test.

“Sex related headaches are a HUGE warning sign. A better test is an MRI angiography with gadolinium or a lumbar puncture done at the time of the headache. Please tell this person to find a new neurologist and get more tests. As an emergency physician, I have seen the tragic end results when patients are reassured by inadequate testing.”

We agree that a full neurological workup is crucial for anyone experiencing sex headaches, for exactly the reason that this physician relays. But there is also such a thing as a “benign sexual headache,” for which some doctors recommend taking ibuprofen or naproxen 30 minutes before sexual activity. Others prescribe the blood pressure drug propranolol or the anti-seizure medicine, Lamictal (lamotrigine).

Only a consultation with your physician and a full medical work-up by an expert will help determine if the kind of sex headache you’re experiencing requires special treatment.