Without a good treatment strategy, migraine can significantly disrupt your daily life and potentially worsen over time - known as chronification. An effective plan should help you become pain-free within two hours and remain pain-free for at least 24 hours, for all your migraine attacks! What is not always realized is that many people need more than one acute treatment available either to use in combination with each other, and/or to use sequentially. This way, if an attack is not easily stopped you have a second or third step to try without having to resort to Urgent Care or the Emergency Room, or trying to reach your clinician's office out of hours!
If you live with migraine, talking with your clinician about acute treatment options ahead of time is key. To help with that conversation, we encourage you to download our Migraine Treatment Toolbox as well as our fillable Migraine Action Plan. We also have an Attack-Based Care Guide that goes into more detail about how to optimize your treatment approach depending on variables for any specific attack. Learn more and expect more from your migraine treatment plan!
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Migraine and the Brain-Gut Connection
Migraine attacks differ. How you treat them should differ too.
Not all migraine attacks are the same. Treatment plans may differ based on many different factors including: the timing of the attack, the pain level, the symptoms, the triggers, and your responsibilities that day. Use our Attack-Based Care Guide to help you figure out how best to treat your next attack.
Build Your Acute Treatment Plan
A well-rounded migraine action plan should include a combination of acute treatment options. Talk to your doctor about prescribing a mix of the following categories so you are prepared for varying attacks.
“Somehow, the idea that acute treatment is supposed to really work well is some kind of a secret for a lot of people. Apparently, many prescribers don’t understand… that this is an achievable goal.”
—Christopher H. Gottschalk, MD
Acute Treatment Options
Yes, effective migraine treatments should aim to alleviate symptoms beyond just pain relief. Treatments should address:
1. Pain Elimination
- Become pain-free within two hours
- Remain pain-free for at least 24 hours
2. Associated Symptoms
- Nausea
- Vomiting
- Light and sound sensitivity
- Cognitive impairment
3. Quality of Life Factors
- Ability to plan and participate in activities
- Feeling confident and in control during attacks
- Preventing emergency room visits
However, current research and clinical trials don't fully capture all migraine symptoms, particularly cognitive impairment. While treatments can significantly improve symptom management, there's still room for improvement in understanding and addressing the full spectrum of migraine symptoms.
The goal is a comprehensive treatment that not only stops pain but helps you return to normal functioning as quickly as possible.
—Dr. Gottschalk
Acute migraine treatments include:
Oral Medications:
- Triptans (sumatriptan, rizatriptan)
- NSAIDs (ibuprofen, aspirin)
- Anti-nausea medications
Non-Oral Medications:
- Injectable triptans
- Nasal spray triptans (Tosymra, Zomig)
- Nasal spray gepants
- Antiemetic suppositories
Medical Devices:
- FDA-cleared neuromodulation devices
- Transcranial magnetic stimulation devices
- Vagus nerve stimulation devices
Combination Approaches:
- Triptans with antiemetics
- NSAIDs with anti-nausea medications
- Combining different treatment formulations
Emerging/Experimental Treatments:
- Ketamine nasal spray
- Compounded medication options
Key Considerations:
- Effectiveness varies by individual
- Non-oral treatments often provide faster relief
- Injectable treatments show highest pain-free rates (up to 75%)
- Combination treatments can improve overall symptom management
The goal is to create a personalized "treatment toolbox" with multiple options to address different migraine intensities and symptoms.
—Dr. Gottschalk
There are six FDA-cleared medical devices, four of which are available only by prescription (learn more HERE).
- Acute treatment of migraine with medical devices is best started early in an attack, ideally within the first 30-60 minutes.
- They are an ideal first-line treatment to use with adolescents to avoid use of medications that have not completed clinical trials for people under 18 years old.
- Medical devices can be used in combination with acute medications.
—Dr. Gottschalk
Non-oral medications like injections and nasal sprays are useful for several critical reasons:
1. Rapid Absorption
- Bypass stomach dysfunction (gastroparesis)
- Deliver medication directly into bloodstream
- Achieve maximum drug concentration within 10-15 minutes
2. Higher Effectiveness
- Injectable triptans show 75% pain-free rates within two hours
- Compared to 20% pain-free rates for oral tablets
- Significantly faster and more reliable symptom relief
3. Overcoming Physiological Barriers
- Work during migraine attacks when stomach stops functioning
- Ensure medication absorption when oral medications fail
- Prevent prolonged or worsening migraine symptoms
4. Treatment Optimization
- Provide a "benchmark" for effective acute treatment
- Help patients understand what's possible in migraine management
- Reduce emergency room visits
5. Comprehensive Symptom Management
- Can be combined with other treatments
- Address multiple migraine symptoms quickly
- Provide confidence in attack management
6. Patient Empowerment
- Give patients more control over their condition
- Reduce anxiety about unpredictable attacks
- Prevent long-term migraine progression
Non-oral medications can offer a more direct, efficient approach to migraine treatment compared to traditional oral medications.
While everyone experiences migraine attacks slightly differently, and likely even has more than one type of attack themselves, there are a few common factors that make achieving our treatment goals challenging. The following 4 scenarios are ones where you should consider asking your clinician about a non-oral medication:
- Nausea and Vomiting
- Gastroparesis
- Wake-Up Migraine
- Fast-Escalating Migraine Attack
In general it is best to treat an attack as early as possible, however there is at least one medication, Ubrelvy, that has shown efficacy when used during the prodrome phase. In this situation, it is important to know what your prodrome symptoms are so that you can treat early and try to avoid the migraine going to the attack phase.
The goal is collaborative communication with your doctor to find the most effective treatment strategy for your specific migraine experience. Be direct and specific about your treatment goals. Show you've done research and ask about creating a comprehensive treatment plan. Request a referral to a headache specialist if needed.
When discussing non-oral medications with your doctor:
Be prepared:
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Track your migraine frequency and severity
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Document current treatment failures
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Bring a detailed migraine diary/action plan
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Note how often you're using emergency services
Conversation Points:
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Discuss percentage of attacks not controlled by oral medications
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Ask about injectable or nasal spray options
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Request specific information about non-oral treatments
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Explain how migraines impact your daily life
Key Questions to Ask:
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Would non-oral medications be appropriate for my migraine pattern?
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What are the potential side effects?
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How quickly might these treatments work?
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Are there insurance coverage considerations?
Red Flags to Discuss:
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Frequent emergency room visits
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Attacks lasting longer than 4-6 hours
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Oral medications consistently failing
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Significant nausea/vomiting preventing oral medication absorption
Bringing this migraine action plan with to your next doctor's appointment can help structure the conversation with your clinician.
General Information
Without a good treatment strategy, migraine can significantly disrupt your daily life and potentially worsen over time. An effective plan should help you become pain-free within two hours and remain pain-free for at least 24 hours. A good treatment plan should:
- Reduce the duration and intensity of migraine attacks
-
Prevent progression from episodic to chronic migraine
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Improve quality of life by allowing you to plan activities with confidence
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Minimize emergency room visits
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Help you feel more in control of your condition
Download this migraine action plan and bring it with you to your doctor's appointment as a great jumping off point for building a personalized plan with your doctor.
—Dr. Gottschalk
Combining different treatment options is crucial for effective migraine management for several key reasons:
1. Physiological Complexity
- Migraine involves multiple body systems
- Different medications target different aspects of the attack
- Helps address stomach dysfunction during migraine
2. Enhanced Treatment Effectiveness
- Combining treatments can improve overall response rates
- Example: Triptan + anti-inflammatory + antiemetic
- Increases chances of becoming pain-free faster
3. Addressing Multiple Symptoms
- Treats pain, nausea, cognitive impairment
- Provides comprehensive symptom relief
- Helps manage different attack intensities
4. Overcoming Treatment Limitations
- No single medication works perfectly for everyone
- Compensates for individual medication weaknesses
- Provides backup options when one treatment fails
5. Faster Symptom Resolution
- Quicker pain relief
- Reduces attack duration
- Prevents migraine progression
6. Personalized Approach
- Allows tailoring treatment to individual symptoms
- Provides flexibility in managing different attack types
- Helps patients feel more in control
The key is creating a flexible "toolbox" of treatments that can be strategically combined to provide the most effective migraine management.
—Dr. Gottschalk
The key is having a comprehensive toolkit that allows you to quickly and effectively manage migraine attacks at various stages, with multiple treatment options that can be combined for optimal relief.
A well-rounded migraine treatment plan should include:
1. Multiple acute treatment options:
- Oral medications
- Non-oral treatments (nasal sprays, injections)
- Medical devices
- Fast-acting medications for different attack intensities
2. Combination treatments:
- Triptans
- Anti-inflammatory medications
- Antiemetics (like Compazine or Reglan)
- Medications to address nausea and stomach issues
3. Preventive strategies:
- Potential preventive medications
- Lifestyle modifications
- Trigger identification and management
4. Emergency protocol:
- Clear guidelines on when to seek medical help
- Backup treatments for severe attacks
5. Personalized approach:
- Tailored to individual symptoms and attack patterns
- Flexible options to address different migraine scenarios
—Dr. Gottschalk
Patients face several key challengess:
1. Insurance Barriers
- Limited medication coverage
- Prior authorization requirements
- Restricted access to non-oral treatments
- High medication costs
2. Medical System Limitations
- Few certified headache specialists (less than 1000 in US)
- Limited migraine education in medical training
- Short consultation times
- Lack of comprehensive understanding of migraine complexity
3. Treatment Accessibility
- Restricted medication quantities
- Limited non-oral treatment options
- Difficulty obtaining injectable or nasal spray medications
4. Personal Challenges
- Fear of injections
- Uncertainty about treatment effectiveness
- Lack of awareness about treatment goals
- Stigma surrounding migraine as a serious condition
5. Treatment Complexity
- Finding the right medication combination
- Managing side effects
- Understanding when to use different treatments
- Tracking and documenting treatment responses
6. Symptom Variability
- Unpredictable attack patterns
- Different symptoms during each migraine
- Challenges in finding a one-size-fits-all approach
The overarching challenge is creating a personalized, flexible treatment plan that effectively manages individual migraine experiences while navigating medical, financial, and personal obstacles.
—Dr. Gottschalk
Untreated or poorly treated migraine attacks can create a cycle of worsening symptoms and reduced overall health and functioning. The consequences of not treating migraine attacks effectively include:
1. Disease Progression
- Higher likelihood of progressing from episodic to chronic migraine
- Studies show ineffective treatments can triple the risk of chronic migraine within a year
2. Neurological Impact
- Migraine attacks cause central nervous system sensitization
- Untreated attacks are like "a fire in your head" that can cause ongoing nerve sensitization
- Repeated untreated attacks can make the brain more susceptible to future attacks
3. Quality of Life Disruption
- Inability to plan activities
- Frequent emergency room visits
- Reduced work productivity
- Social isolation
- Constant anxiety about potential attacks
4. Physiological Complications
- Persistent stomach dysfunction (gastroparesis)
- Prolonged nausea and vomiting
- Potential cognitive impairment
- Extended recovery times
5. Psychological Effects
- Increased stress and anxiety
- Loss of confidence in managing health
- Potential development of depression
—Dr. Gottschalk
Patient education is important in managing migraine for several key reasons:
1. Treatment Understanding
- Patients learn what effective treatment should look like
- Understand the goal of becoming pain-free within two hours
- Recognize that migraine is a complex neurological condition
2. Advocacy and Empowerment
- Learn to ask for appropriate treatments
- Understand their right to comprehensive care
- Challenge insurance barriers and medical misconceptions
3. Treatment Optimization
- Know how to build a comprehensive treatment toolbox
- Understand combining different medication types
- Learn to track and document treatment responses
4. Preventing Disease Progression
- Understand how untreated attacks can lead to chronic migraine
- Recognize early intervention strategies
- Learn about potential long-term consequences
5. Symptom Management
- Identify individual triggers
- Understand the full range of migraine symptoms
- Learn strategies beyond medication
6. Breaking Stigma
- Challenge misconceptions about migraine
- Promote understanding of migraine as a serious neurological condition
- Improve communication with healthcare providers
7. Personal Health Management
- Develop proactive approach to treatment
- Create personalized action plans
- Build confidence in managing the condition
The ultimate goal is to transform patients from passive recipients of care to active, informed participants in their migraine management.
—Dr. Gottschalk
About Dr. Gottschalk
Christopher H. Gottschalk is currently Director of the Yale Headache & Facial Pain program and Chief of the section of General Neurology. He was UCNS board-certified in Headache Medicine in 2012 and was made Fellow, AHS, in 2014, where he is active in curriculum development, working to establish milestones for Headache Medicine knowledge and practice.
Dr. Gottschalk’s primary research interest is in education—from neurology trainees and Primary Care physicians to the general public—regarding the facts of headache disorders and the fictions that interfere with their recognition and treatment.