Migraine Management: Triggers and Treatments

Treatment divides into two categories that are often confused: acute treatment to stop an attack in progress, and preventive treatment to reduce how often attacks occur.

The phases of an attack

Many people experience a prodrome hours or a day beforehand — mood change, food cravings, yawning, neck stiffness. Recognising it allows earlier treatment, which works considerably better.

Aura affects a minority and typically involves visual disturbance developing over minutes, sometimes with sensory or speech symptoms.

The headache phase and then a postdrome, where people often feel drained for a day afterwards.

Acute treatment

Simple analgesics work for some attacks, particularly taken early and at adequate dose. Anti-nausea medication can help both the nausea and the absorption of other medication.

Triptans are migraine-specific and effective for many people. Taken early in the headache phase they work considerably better than when delayed. Several exist and response varies, so a trial of a different one is reasonable if the first is ineffective.

Newer classes of acute treatment have become available in recent years and provide options for those in whom triptans are unsuitable or ineffective.

Medication overuse headache

This is important and widely under-recognised. Taking acute painkillers frequently — commonly cited as more than around ten to fifteen days a month depending on the drug — can itself cause a persistent daily headache.

The pattern is a gradual increase in headache frequency alongside increasing medication use. Breaking the cycle requires withdrawal, which is unpleasant and usually needs medical support.

Tracking how many days a month you take acute medication is worth doing for this reason alone.

Preventive treatment

Considered where attacks are frequent, prolonged or poorly responsive to acute treatment. Several classes are used including certain blood pressure medications, antidepressants and antiepileptics, chosen partly on side effect profile and other conditions.

Newer preventive treatments targeting a specific pathway involved in migraine have become available and represent a meaningful advance for those who have not responded to older options.

Preventives take weeks to work and need an adequate trial before concluding they have failed.

Triggers, honestly

Trigger identification is useful but frequently over-attributed. Some apparent triggers are actually early prodrome symptoms — craving chocolate before an attack is not the same as chocolate causing it.

Reasonably well-supported factors include irregular sleep, skipped meals, dehydration, alcohol, hormonal fluctuation and stress, including the let-down after stress rather than during it.

A headache diary recording attacks, medication days and possible contributors is the most useful tool available, both for identifying patterns and for guiding treatment decisions.