Treatments for Chronic Migraines: Latest Advances for Lasting Relief

Migraines are more than just bad headaches. They’re a complex neurological condition that can cause vision changes, nausea, vomiting, and severe pain that can last for hours or even days. Most people have “episodic” migraines, meaning they have episodes once in a while. But about 3% of people with migraines experience chronic migraines. This group experiences migraines at least 15 days a month. 

People with chronic migraines can have their lives upended. Cycling through back-to-back migraine episodes makes it hard — if not impossible — to get through the day. So there’s clear urgency for getting chronic migraine treatment. While there’s no cure for chronic migraines, finding the right treatment plan can give people more pain-free days. 

What are the treatment options for chronic migraine?

Chronic migraine treatment involves a combination of:

• Avoiding triggers

• Migraine prevention

• Real-time pain relief

By using all three techniques, people can have more headache-free days. Treatment can also help migraines feel less intense when migraines do break through, and people don’t have to take as much medication. 

1. Avoiding triggers

The first step in managing chronic migraines is avoiding triggers. Without this step, even the best medications may not be enough to prevent migraines. 

Most people can easily pinpoint their migraine triggers. These are things like foods, light, sounds, or even smells that usually bring on a migraine. If you know your triggers, it’s important to avoid them as much as possible. If you don’t know your triggers, try keeping a headache diary. 

When you feel a migraine starting, write down the date, time, and your symptoms. But also note what you were doing when the migraine started. You may find that your episodes tend to happen more at a specific time of day or in certain locations. This can help you pinpoint your triggers.  

Triggers do vary from person to person. But there are some things that are likely to trigger a migraine for people. These things include:

• Not getting enough sleep 

• Skipping meals

• Not drinking enough water (dehydration)

• Experiencing stress

• Drinking too much caffeine

As part of your treatment plan, you may need to work on some of these areas. 

2. Migraine prevention

Migraine prophylaxis are medications that you take regularly to stop migraines from starting. These medications can give you more pain-free days and also keep you from taking too much pain-relieving medication, which can actually worsen migraines. 

Finding the right migraine prevention can take time. Not everyone responds to these medications the same way. If your first treatment option doesn’t work, don’t get discouraged. There are several first-line and second-line treatment options available. And remember to give the medication time. It can take up to 8 weeks to really feel the effects of these treatments.

Here are some of the most common migraine prevention treatments.

Topiramate

Topiramate (Topamax, Qudexy XR) is a medication used to treat and prevent seizures. But researchers found that it also prevented chronic migraines. In studies, people who took topiramate daily had fewer headaches. 

Divalproex sodium

Divalproex sodium (Depakote) is another antiseizure medicine that can prevent migraines. This medication appears to increase a brain chemical called GABA, which can prevent migraines. You cannot take this medication if you’re pregnant. 

Propranolol

Propranolol is a beta blocker that treats high blood pressure and other heart conditions. But researchers have found that propranolol also helps prevent migraine headaches. Experts think it may work to prevent nerve cells from overworking, which can lead to migraines. 

Amitriptyline

Amitriptyline (Elavil) is an older medication that can be used to treat depression. It’s also used to help prevent migraines. Other antidepressants may also prevent migraines, but they’re used less frequently than amitriptyline. Unlike some other options, people may notice fewer headaches in as little as 4 weeks.

OnabotulinumtoxinA (Botox)

People often think of Botox being used for cosmetic purposes like removing wrinkles. But Botox injections are also a treatment for chronic migraine prevention. The FDA approved Botox for chronic migraines in 2010, and studies show that it can offer people on average 2 more headache-free days each month. 

Unlike the other options above, Botox is a second-line therapy. That means healthcare providers will try other options first before recommending Botox. It also means that insurance companies might not cover this treatment until you try a first-line treatment.

Calcitonin gene-related peptide (CGRP) antagonists

Calcitonin gene-related peptide (CGRP) antagonists are the newest chronic migraine treatment option. They block a protein in the brain that seems to play a role in triggering migraines. 

The FDA first approved these medicines in 2018 and were only available as injections or intravenous (IV) infusions. These include:

• Erenumab (Aimovig)

• Galcanezumab (Emgality)

• Fremanezumab (Ajovy)

More recently, oral tablets have received FDA approval, making them easier to use. Some options include:

• Rimegepant (Nurtec)

• Atogepant (Qulipta)

Like Botox, these are second-line treatments, so you may need to try other medications first.

3. Headache relief

Even if you’re steadfast about avoiding triggers and you find the right prevention medications, migraine breakthroughs are bound to happen. That’s why there’s a part of treatment that focuses on real-time headache and relief. These are sometimes called “abortive” treatments. The hope is that with the right treatment and trigger avoidance, you won’t need to rely on these pain relievers as often. 

Triptans

Triptans are a class of medication that can relieve migraines once symptoms start. They’re a first-line treatment option for migraine relief and are available as pills, dissolvable tablets, injections, powder, and nasal sprays.

There are seven available triptans:

• Sumatriptan (Imitrex, Zembrace SymTouch, Onzetra Xsail, Tosymra, Treximet)

• Zolmitriptan (Zomig, Zomig-ZMT)

• Rizatriptan (Maxalt, Maxalt-MLT)

• Eletriptan (Relpax)

• Frovatriptan (Frova)

• Naratriptan (Amerge) 

• Almotriptan (generic only)

There’s no one triptan that’s considered to work “best.” But you might find that one or more works better for you. 

Calcitonin gene-related peptide (CGRP) antagonists

Calcitonin gene-related peptide (CGRP) antagonists don’t just prevent migraines, they can also treat migraines after they start. They’re considered a second-line therapy. 

CGRP antagonists that are FDA-approved for migraine treatment include:

• Rimegepant (Nurtec)

• Ubropagent (Ubrelvy)

• Zavegepant (Zavzpret)

Over-the-counter (OTC) pain relievers

Some people find that acetaminophen (Tylenol) or ibuprofen (Motrin) provide enough pain relief when they have a migraine. These medications are inexpensive and available over the counter, making them popular options.

Are there natural or alternative therapies for migraines?

Some people prefer to limit how much medication they take. You may consider adding natural remedies or alternative therapies to your treatment for chronic migraine. 

While there’s not always a lot of research to support these options, some people have found relief by adding these things to their treatment plans. Popular options include:

• Vitamins and supplements like magnesium, riboflavin, and coenzyme Q10

• Essential oils

• Acupuncture

• Biofeedback

• Mindfulness-based therapies

Remember, you can add these treatments to your care plan but be sure to talk with your healthcare provider about them first. This way, you can avoid medication interactions or other unwanted side effects. 

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Written by:

Brian Clista, MD

Dr. Clista is a board-certified pediatrician who works in private practice in Pittsburgh, Pennsylvania. He previously served as a National Health Service Corporation Scholar in the inner city of Pittsburgh for 11 years.

Edited by:

Patricia Pinto-Garcia, MD, MPH

Patricia Pinto-Garcia, MD, MPH, is a medical editor at GoodRx. She is a licensed, board-certified pediatrician with more than a decade of experience in academic medicine.

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