Paul G. Mathew, MD, FAHS
Brigham and Women’s Hospital
Department of Neurology
John R. Graham Headache Center
Boston, Massachusetts
Cambridge Health Alliance
Division of Neurology
Cambridge, MA
Harvard Medical School
Boston, MA
Migraine is a common headache disorder that affects
approximately 1 in 5 women and 1 in 20 men. It is
a complex disorder, which tends to be inherited in
families, and in recent years more genes have been
identified that play a role in the genesis of migraines.
Although many sufferers will deny a family history
of migraines, the truth of the matter is that they
actually have family members who suffer with
migraines. Some family members have infrequent
migraines, and down play the level of disability
that they suffer by calling it “my normal headache.”
Alternatively, family members often blame another
disease process for their symptoms such as a sinus
infection or the flu, when they are actually in denial
or fail to realize they are experiencing a migraine.
Migraine medication treatment can be divided
into two major categories. Abortive medications
are medications that are taken at the time of a
migraine attack for termination of the headache
and associated symptoms. Abortive medications
include many different classes including nonsteroidal
anti-inflammatory drugs (ibuprofen, naproxen),
triptans (sumatriptan, rizatriptan, naratriptan,
almotriptan, zolmitriptan, frovatriptan, eletriptan),
ergotamines (dihydroergotamine), and anti-nausea
agents (metoclopramide, promethazine). Preventative
medications, as the name implies, are taken on
a daily basis to prevent migraine attacks from
occurring. Preventative medications include many
different classes, such as blood pressure medications
(verapamil, atenolol, propranolol, nadolol, timolol,
metoprolol), tricyclic antidepessants (amitriptyline,
nortriptyline, protriptyline), anti-seizure medications
(topiramate, gabapentin), and injectable therapies
such as botulinum toxin (Botox, BTX).
Although people with migraines can suffer from
similar symptoms such as throbbing pain, nausea,
vomiting, and sensitivity to light, sound, and smell,
individual patients can have very different responses to
treatment. As such, it is not uncommon for physicians
to try several different medications before finding
the right combination of abortive and preventative
medications to adequately control a patient’s headaches.
This approach in most cases leads to an improvement
of headache frequency and intensity. However, in
some cases, it may require months to achieve a good
outcome as each medication trial can typically take
weeks. For some medications, side effects can limit
increasing the dose to one that would be effective
for the treatment of the patient’s migraines.
Considering the large number of individuals
experiencing migraine, the inadequate number of
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