Have you ever been given a new preventive migraine medication, only to get home and realize that you have nothing to stop an actual attack when it happens? Have you ever been given a prescription for an acute medication that is a tablet, only to discover that you don’t know what to do when you throw up immediately after swallowing the pill? Has your doctor explained how long a preventive treatment might take to kick in? Have they made sure you know what to do when an acute treatment fails to work and you don’t know how to stay out of the emergency room? These and many other scenarios like them are tragically way too common. The reality is that most migraine patients do NOT leave their doctor’s appointment with a comprehensive treatment plan – something we like to call a Migraine Action Plan. But this is not the end of the story!
Is It Really Not Just a Headache?
Anyone with frequent migraine is all too aware of how debilitating the symptoms of a migraine attack can become. Sometimes we can push through, but often they stop us in our tracks, disrupting our daily activities and responsibilities, and causing frustration, anger, fear, depression or even hopelessness. In some cases, the consequences can include being unable to work a full-time job, deciding not to have children, stopping your education sooner than expected, or loss of relationships. While many people still are under the false impression that a migraine attack is “just a headache,” or that an aspirin or ibuprofen will do the trick, the truth lies far from these impressions. In reality, migraine disease is a complex neurological disorder that often requires a combination of treatments, and without an effective treatment plan it can be disabling.
The American Headache Society recommends that anyone with 4+ days of migraine a month should be on a preventive treatment option, or even with fewer than 4 but the attacks are disabling. This is in addition to any acute treatment needed! On the Migraine Meanderings website we offer a FREE downloadable migraine toolbox. This resource covers medications, medical devices, supplements, alternative treatments, over the counter options, and lifestyle changes. At first glance this can seem like a lot of information, and overwhelming. But as many of us have admitted, trying to manage frequent debilitating migraine attacks without a written plan can be like living in tornado alley. The ideal goal for people with migraine is to work with their doctor to create a comprehensive Migraine Action Plan that includes preventive, acute, and also rescue options for when nothing else works:
- Preventive: Preventive medicines and medical devices can help reduce the severity and frequency of migraine attacks.
- Acute/abortive: Acute medicines and medical devices can help stop migraine attacks and associated symptoms.
- Rescue: Rescue medicines and other interventional options are used when acute treatments are contraindicated or simply fail to work. Sadly, this happens way too frequently for many people.
What’s Important When Creating a Migraine Action Plan?
As you work with your headache doctor to create a comprehensive Migraine Action Plan (MAP), you’ll quickly see that, as with all things migraine, even this is not simple! It’s important to let your doctor know all your migraine symptoms, how quickly attacks escalate, how frequently you get attacks, and any other medical conditions you have. For each section of the MAP, try to bear the following in mind:
- Preventive Treatment Speed: Often patients will leave their doctor’s office with a new preventive treatment, not realizing that the treatment may take 3 months or more to start working. Yes, in some unusual circumstances preventive medications can kick-in quickly, it is far more common to expect around 3 months. This is also true with FDA-cleared medical devices for preventive migraine treatment. Not only is it important to know what to expect in terms of timeframe, but also any dosing changes or options to combine treatments. One of the saddest things we often hear in our online community is when a patient posts that they have started a new preventive. However, one or two weeks into their treatment and they have a massive migraine attack and realize they don’t have any way to stop it. It’s important to talk to your doctor about having acute treatments to use while the preventive has a chance to work. Realistically, most preventives do NOT stop all attacks, so you will need to have at least one acute treatment in hand anyway.
- Acute Treatment Speed: Is this a fast-acting option or does it take an hour or two to kick in? If you are able to start treatment early on then a medical device or oral medication may work fast enough. However, if you have a “wake-up migraine” or “rapid onset migraine”, a nasal spray or injection may be the fastest and most reliable way to treat the attack.
- Safety & tolerability: Does the treatment conflict with any other medical conditions you have or medications you take? Are the potential side effects likely to be tolerable for you? This is going to be true for both acute and preventive treatment options. In some cases there may be an intolerable side effect, but the risk is outweighs the potential benefit. Or, you may be able to add something else to manage the side effect; such as an anti-emetic for nausea or PPI medication for reflux. Tolerability is a very personal decision, so don’t be afraid to speak up with your doctor!
- Ease of use: This is something that is often overlooked. For example, if you are prescribed a preventive injection to use at home, then you need to make sure that you know how to use it and are willing to give yourself an injection! Another example might be a prescription for a pill that you can’t get out of the wrapper during an attack, or a device that is too large to carry around with you at all times. It may also be needing to fill a syringe with a medication while dealing with vision loss, vomiting, or dizziness.
- Cost: Medications, whether they are preventive or acute, oral or non-oral, need to be affordable for you. If your insurance copay is too high, or your doctor’s preferred options are denied by your insurance, you can appeal. Your doctor can send in a prior authorization, formulary exception due to medical necessity, or even request a formulary tier change. It’s important to know that “Denied!” is not the end of the story. Advocate for yourself when this happens, many denials can be overridden!
- Generic vs Name Brand: Insurance companies love to push out generic medicines rather than name brand whenever possible. The reality is that even if the “key ingredient” is the same, the other ingredients, as well as the way the medication is administered, can differ. What this means is that sometimes a brand medication truly may be the best option for treatment even if a “comparable” generic is available. It’s important to work with your doctor to find the best option for you, and then work through any insurance hurdles presented.
Use a Migraine Action Plan as a Treatment Guide
A Migraine Action Plan (MAP) is a written guide developed by you and your doctor to better manage migraine disease. The MAP is a personalized document that explains not only a preventive protocol, but also which acute migraine treatments to use, when to use them, what the right dose is, whether you can combine multiple options, and what the best option is based on your symptoms or the current stage of a migraine attack. You can download a free printable Migraine Action Plan to take to your doctor!
It may take a little time to get a Migraine Action Plan (MAP) completed by your doctor. However, it is important for several reasons:
- Improved disease management: People that utilize a comprehensive MAP are able to prevent and treat migraine attacks more effectively. Period! You will easily see the overall plan to get your migraine under control, for both prevention and acute treatment.
- Better conversations with your doctor: You and your doctor will develop the MAP together. This helps you build trust with each other and improve communication. For example, your doctor will learn what your specific prodrome signs, aura or symptoms are. You will know that you have different options to utilize depending on the type of attack you are dealing with.
- Fewer emergency or urgent situations: If your normal treatment fails, the Migraine Action Plan provides options and clear steps on what to do during an attack. This means you do not need to rely on trying to reach your doctor out-of-hours, going to urgent care or the emergency room. It will also explain when the ER IS the best option or when you DO need to call your doctor’s office urgently!
Where Do We Go From Here?
The most important first step is to talk with your doctor about your migraine treatment options. Make sure they are aware of all your symptoms, what your migraine attacks are like, and what your primary goals are for acute migraine treatment. This is where your voice matters and advocating for yourself is key!
Let us know…
Have you tried a non-oral migraine treatment? Has your doctor ever offered to prescribe a nasal spray or injection? If so, has this helped you better manage your migraine attacks?