Migraines affect 38 million people in the U.S. They can range from mild to debilitating and they may come on without any warning. Sharon Bergquist, MD, of Emory Healthcare, details what she discusses with her patients when they need help treating migraines. 1. Q: How are migraines defined? A: A very severe headache, usually unilateral (affecting one side of the head), often accompanied by nausea and vomiting is considered a classic migraine. Sometimes, migraine patients will see an “aura,” typically of flashing lights around the eyes, prior to the onset of the migraine. There are many variations on this. Some migraines are bilateral (affecting both sides of the head), some don’t involve nausea or vomiting, and some aren’t preceded by an aura. Migraines are a bit of a puzzle: we don’t know their exact cause, but they may occur from a chain reaction of neurologic and biochemical events that ultimately affect blood vessels in the brain. 2. Q: How do you know if it’s a migraine or a headache? A: Several factors can help differentiate a migraine from other types of headaches. The first is the location of the pain. If it’s felt on one side of the head, it’s usually a migraine. Severity is another factor. I ask patients to rank their pain from 1 to 10. That can be very subjective, but migraines are typically a seven or above--especially if accompanied by nausea, vomiting, or an aura. Age matters as well: it would be unusual to get your first migraine at age 50. Migraines typically begin in your 30s or earlier. So if someone older than 50 who has never had a migraine before comes to see me with a severe headache, I look for other causes. Sinus headaches are often mistaken for migraines—a sinus headache will manifest in painful pressure around the cheeks and eyes. Another common type of headache easily mistaken for migraines is a classic tension headache. Tension headaches cause pain in both sides of the head near the temples, the forehead, or the top of the head. 3. Q: How do you reduce the pain of a migraine? A: We treat migraines two ways: we relieve the pain, and we also try to reduce their frequency or prevent them altogether. As far as treating migraine pain, general pain relievers, like ibuprofen (Advil), naproxen (Aleve), and acetaminophen (Tylenol) may be enough for mild migraines. Those are the ones where you can still drive to work and have a normal workday. Some migraine-specific pain relievers, like Excedrin Migraine, which combines aspirin, acetaminophen, and caffeine, can also be helpful. For more moderate to severe pain, I prescribe medication from the family of triptans or ergots, which specifically target the underlying migraine pathology. Triptans go by names such as sumatriptan (Imitrex), rizatriptan (Maxalt), and almotriptan (Axert). They temporarily narrow blood vessels and block pain pathways in the brainstem. They are also serotonin receptor agonists because they increase the level of serotonin, a brain chemical messenger thought to drop during a migraine. Drugs containing ergotamine are called ergots—they’re older and generally less effective than triptans. They’re often combined in a pill with caffeine to make them more impactful. Ergots work similarly to triptans in that they constrict blood vessels. Although triptans are more commonly prescribed, ergots have been found to be helpful to patients with migraines lasting longer than 48 hours. If you are given ergots, your doctor will either prescribe a medication called dihydroergotamine (DHE), which can be injected or taken as a nasal spray called Migranal; or ergotamine, which comes in the form of oral tablets, sublingual tablets (tablets taken under the tongue), and rectal suppositories. For patients who experience nausea, I also prescribe an anti-nausea medication. 4. Q: What do you prescribe to prevent migraines? A: If you have more than four migraines a month, your migraines last longer than 12 hours, or if your migraines are debilitating, it’s worth considering taking a medication to prevent them altogether. There are several different types of drugs to choose from. I commonly prescribe the tricyclic antidepressant amitriptyline (Elavil), which works on the serotonin pathway thought to be associated with migraines. A beta-blocker like propranolol (Inderal), which also lowers blood pressure, is another option. And drugs that were originally approved to treat epilepsy have now been approved to prevent migraines; currently, topiramate (Trokendi XR, Topamax) and valproate (Depakene) are on the market. Additionally, a new class of drugs called CGRP blockers were recently developed specifically to prevent migraines. These drugs, including erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality) target a molecule thought to instigate migraines and increase their severity. Erenumab and galcanezumab are self-injected monthly, and fremanezumab is injected by the patient or a doctor either monthly or once every three months. Each of these medications has side effects that your doctor will take into account when deciding which one is best for you. 5. Q: What other ways can patients manage their migraines? A: An underestimated way to prevent or ease a migraine is through your lifestyle. Sleep, sleep, sleep! That is extremely important. I also tell my patients to stay well hydrated by drinking enough water. Eating regular meals to avoid hunger and exercising regularly can reduce the frequency of migraines. And the hardest but perhaps most critical strategy is lowering stress as much as possible. So really, just living a healthy life by sleeping enough, staying hydrated, staying satiated, reducing stress, and being active can make a big difference.