What helps against migraines?

What helps with migraine? General tips

Migraine treatment consists of relieving acute migraine attacks and preventing new attacks. Various medications are used for this purpose. In addition, non-drug methods offer help with migraine. Neither of these methods can cure the headache disorder, but they can help control it. More about these therapies below.

Apart from this, sufferers can significantly influence the severity and frequency of attacks through their own behavior. Here are some important general tips against migraine:

Avoid triggers for your migraine: What can you do to prevent a migraine attack in the first place? The clear answer: avoid as far as possible all factors that you know can give you a migraine. These can be certain foods, skipped meals, sauna visits and/or hectic and stressful everyday life.
Retreat in acute cases: During an acute attack, you should retreat to a darkened room if possible, turn off sources of noise such as the television or radio, and lie down.
Take painkillers at an early stage: It is best to take a suitable painkiller at the first signs of a migraine attack. Then the attack can sometimes be stopped, because painkillers work more effectively when taken early.

However, be careful not to take headache or migraine medications too frequently. Otherwise, they can trigger the pain themselves (drug-induced headache).

How can migraine be treated with medication?

Various medications are suitable for the acute treatment of a migraine attack. It can also be useful to take preventive medication to reduce the number and severity of attacks (migraine prophylaxis with medication).

Medication in acute cases

Very often, a migraine attack is accompanied by nausea and vomiting. So-called antiemetics help against this. For the pain itself, conventional painkillers (analgesics) such as ibuprofen or – in the case of more severe symptoms – special migraine drugs (triptans) are recommended. In exceptional cases, ergot alkaloids are used.

Some of these drugs require a prescription, such as most triptans. Others, however, are available over the counter at pharmacies, such as ibuprofen or the triptan naratriptan. But even then, a doctor should be consulted beforehand on the choice and dosage.

Antiemetics

Antiemetics not only counteract nausea and vomiting, but also enhance the effect of the analgesics taken afterwards.

Analgesics

For mild to moderate migraine attacks, (mostly over-the-counter) analgesics are used.

These include, above all, acetylsalicylic acid (ASA) and ibuprofen – two representatives of the so-called non-steroidal anti-inflammatory drugs (NSAIDs). Their efficacy against migraine is the best proven of all analgesics. ASA is taken in high doses, preferably as an effervescent tablet, because it is then quickly absorbed into the body and can thus develop its effect rapidly. Taking ibuprofen in soluble form is also advantageous.

ASA and metamizole can also be administered as an injection against migraine. Doctors do this for emergency treatment of a migraine attack – for example, when patients seek medical help because oral medications (e.g., tablets) do not help against the migraine pain.

Combination medications:

There are also combination preparations for medicinal migraine therapy, such as the triple combination of ASA, paracetamol and caffeine. With such combined drugs, one must be especially careful not to use them too frequently if one does not want to risk a drug-induced headache:

The threshold for the development of a headache caused by the overuse of painkillers is ten or more days per month of use for such combination preparations. In comparison, this threshold for a painkiller taken individually (monopreparation) is 15 or more days per month.

Triptans

As so-called serotonin receptor agonists, triptans bind to the same receptors in the brain as the nerve messenger serotonin. This prevents the latter from docking, which reduces the headache and its accompanying symptoms (such as nausea). At the same time, the blood vessels in the brain constrict, which can relieve the pain of a migraine.

Triptans work best when used as early as possible in the headache phase of an acute migraine attack. For migraine with aura, use is recommended only after the aura has subsided and the headache has started – for safety reasons and because the drugs are unlikely to work if given during the aura.

Various triptans are available. Quite rapid relief from migraine can be achieved with sumatriptan or zolmitriptan, for example. Other triptans, such as naratriptan, have a slower onset of action but last longer.

Certain preparations of some triptans (such as naratriptan) are available without a prescription. Nevertheless, medical advice is necessary in advance. In some cases, the migraine medications may not be used at all or only to a limited extent. They are not recommended, for example, for severe cardiovascular diseases (such as after a heart attack or in the case of “smoker’s leg”). In cases of mild kidney or liver weakness, it may be necessary to reduce the maximum daily dose.

If triptans fail or the headache recurs:

If triptans do not adequately treat the migraine headache, they may be combined with a nonsteroidal anti-inflammatory drug (NSAID) such as naproxen.

Recurrent headache is also possible after the use of ASA, but much less frequently than after the administration of triptans.

Ergot alkaloids (ergotamines).

Another group of medications that may provide help for migraine is ergot alkaloids (ergotamines). However, because they are less effective than the previously mentioned drugs and also cause more side effects, they are only recommended for the treatment of acute migraine attacks in exceptional cases – for example, in patients with a particularly long attack. Here, the longer duration of action of ergotamines (compared to that of triptans) can be an advantage.

Cortisone

Corticosteroids (colloquially: “cortisone” or “cortisone”) for migraine are administered by doctors in the event of an attack lasting longer than 72 hours: in such a migraenosus status, patients receive a single dose of prednisone or dexamethasone. According to studies, this can reduce the headache and reduce recurrent headaches.

There are other drugs or drug combinations that are sometimes used to treat acute migraine attacks – although randomized-controlled trials (clinical trials of the highest quality) are lacking. These include:

acetylsalicylic acid (ASA) + vitamin C
Acetylsalicylic acid (ASA) + caffeine
Aceclofenac
Acetamicin
Etoricoxib
Ibuprofen lysine
Indometacin
Meloxicam
Paracetamol + caffeine
Parecoxib
Piroxicam
Propyphenazone
Tiaprofenic acid

An efficacy of cannabis against migraine is also often cited. Corresponding evidence is provided, for example, a US study from 2019, in which the data of a medical cannabis app were analyzed. It was the information of headache and migraine patients on symptoms before and after the use of different cannabis doses and varieties.

Apart from this, another recent study found an association between the use of cannabis and the occurrence of medication-induced headache: patients with chronic migraine who used cannabis were more likely to develop a headache triggered by overuse of painkillers than migraine patients without cannabis use.

In conclusion, the use of cannabis for migraine needs further research.

Medication for migraine prevention

Many sufferers manage to prevent migraine attacks with non-drug measures (see below). Sometimes, however, it can also be useful to take additional medication for prevention.

Three or more migraine attacks occur per month, affecting the sufferer’s quality of life.
The attacks regularly last longer than 72 hours.
The attacks do not respond to the acute therapy recommendations described above – including triptans.
The side effects of acute therapy are intolerable to the patient.
The frequency of attacks increases, and the patient therefore resorts to painkillers or migraine medications on more than ten days per month.
These are complicated migraine attacks with debilitating (e.g., hemiplegia) and/or long-lasting auras.
There is a known history of migrainous cerebral infarction, although other causes of infarction have been ruled out.

What migraine prophylactics are available?

A wide variety of active ingredients are available for migraine prophylaxis. Most of them were originally developed for other indications, but some were later approved for migraine prophylaxis.

Means of high/good scientific evidence: The preventive efficacy against migraine attacks is very well proven for the following migraine prophylactics:

Propranolol, metoprolol, bisoprolol: These belong to the beta-blocker group and as such can lower blood pressure.
Flunarizine: This so-called calcium antagonist (calcium channel antagonist) is used not only as a preventive agent against migraine, but also against dizziness.
Amitriptyline: This is a tricyclic antidepressant. In addition to depression and nerve pain, it is also used to treat migraines.
Onabotulinumtoxin A: Some people suffer from migraines almost constantly. What often helps then are injections with onabotulinumtoxin A. This form of Botox can have a preventive effect on chronic migraines.

The preventive efficacy of propranolol, metoprolol, flunarizine, valproic acid, topiramate, and amitriptyline against migraine is best supported by controlled trials.

Agents of lower scientific evidence: there are also migraine prophylactics whose efficacy is less well established. These include:

Opipramol: a tricyclic antidepressant, but only used off-label for migraine prevention.
Acetylsalicylic acid: in low doses, marginal efficacy as a migraine prophylactic.
Magnesium + vitamin B2 + coenzyme Q10: There is only evidence in small studies on the efficacy of high-dose vitamin B2 in migraine. There are contradictory study results on the efficacy of coenzyme Q10. The combination of the three substances can reduce the severity of migraine attacks, but not their frequency.
Lisinopril: a so-called ACE inhibitor; used “off-label” for migraine prophylaxis.
Candesartan: an antihypertensive; also used “off-label” for migraine prevention.

These are artificially produced antibodies that target the messenger substance CGRP (eptinezumab, fremanezumab, galcanezumab) or its docking sites, the CGRP receptors (erenumab). CGRP (Calcitonin Gene-Related Peptide) is currently known to be involved in the development of migraine headaches.

The already approved antibodies can be prescribed for episodic migraine (with at least four migraine days per month) as well as for chronic migraine as a second-line preventive agent.

Herbal preparations: In connection with migraine prophylaxis, herbal preparations are often mentioned, for example with butterbur or motherwort:

Also in two studies, a CO2 extract of motherwort (Tanacetum parthenium) was able to show its preventive effect against migraine. However, motherwort is not marketed in this form in Germany and Austria. Other forms of motherwort have not been studied for their efficacy in migraine, so they cannot be recommended for this purpose.

Course and duration of medicinal migraine prophylaxis

Preventive use of Botox for chronic migraine is in the form of injections: The drug must be injected repeatedly at intervals of about three months for a lasting and increasing effect. If the chronic migraine has not improved after the 3rd cycle, the therapy is discontinued. In about every second patient, however, Botox is effective against the migraine to such an extent that further injection cycles can be dispensed with.

The monoclonal antibodies for migraine prophylaxis are administered at intervals of several weeks as an injection under the skin or infusion. The application should initially extend over three months. If it has not yet shown sufficient effect, the therapy is discontinued. However, if the therapy is successful, the antibodies continue to be administered. After six to nine months, however, they should be discontinued on a trial basis to determine whether further use is still necessary.

How can migraine be treated non-drug?

As effective as medications are in acute cases and for the prevention of migraine: What else helps against the painful attacks? In fact, there is a whole range of non-drug measures that can be used to treat a migraine – primarily as a preventive measure, but sometimes also during an acute attack.

Advice

The first important non-drug measure for migraine prophylaxis is a detailed consultation and explanation of the clinical picture by the treating physician. Even a consultation of at least 30 minutes can noticeably reduce the number of headache days and the pain-related impairments of patients.

Sports

It is still unclear whether the effectiveness of sport in migraine is based on non-specific effects (sport as a relaxation method) or on specific effects. It is also possible that a sport-induced loss of excess pounds contributes to the effect – severe overweight seems to be associated with more frequent headache attacks.

As long as these questions remain unresolved, it is difficult to make general recommendations about the frequency, duration, and intensity of exercise training for migraine prophylaxis. Migraine sufferers are best advised to seek individual advice from their physician or a sports medicine specialist.

Relaxation techniques

Relaxation techniques can provide effective and lasting help for migraine: Used regularly, they help relieve stress and in many cases can reduce the frequency of migraines.

Autogenic training is also effective for migraine prevention. However, this relaxation method is more difficult to learn and requires more practice.

Those who do not like these relaxation methods can try others. For example, some patients rely on Tai Chi, meditation or yoga against migraine.

Biofeedback

Biofeedback has proven to be very effective in migraine prevention – it is even suitable as an alternative to migraine prevention with medication. In this therapy method, patients learn to actively control processes in the body that actually occur unconsciously (e.g. heart rate, muscle tension). The processes are usually measured by sensors attached to the body and reported back to the patient in the form of acoustic or visual signals. The patient then tries to change a process by willpower – for example, by deliberately lowering the pulse rate. If it works, the change is indicated audibly or visibly.

Cognitive behavioral therapy

An effective method of migraine treatment without medication is cognitive behavioral therapy (CBT). Its overarching goal is to make sufferers experts in their own right, who can use different coping strategies depending on the situation.

To this end, the patient analyzes and improves his or her handling of stress, among other things, during individual or group therapy. Negative thought patterns that can cause stress are also worked on. Overall, patients develop a stronger sense of self-efficacy and control. This means that they no longer feel powerless in the face of attacks, but have the confidence to influence their illness.

Pain management techniques help during an acute migraine attack. Patients learn to distance themselves from the pain, for example in the form of attention control and imagination exercises.

Good efficacy

Cognitive behavioral therapy treatment approaches can significantly reduce headache days per month and headache-related psychological problems (catastrophizing, anxiety, depression). Cognitive behavioral therapy approaches have also been shown to be highly effective compared to drug treatments. The combination of CBT and medication-based migraine prophylaxis is particularly useful: it is more effective than either of these therapies alone.

The patients who benefit most from cognitive behavioral therapy are those who place very high demands on themselves, suffer frequent attacks, and clearly react to stress with migraine attacks. However, CBT can also help other migraine sufferers.

Cognitive behavioral therapy is generally performed by licensed psychological psychotherapists.

Interventional procedures

Occipital nerve block

Whether the procedure also helps with an acute migraine attack has not yet been adequately studied.

Non-invasive nerve stimulation (neurostimulation)

This term covers procedures in which certain nerves are stimulated via the skin – without perforating it – such as transcutaneous electrical nerve stimulation (TENS). Studies on the efficacy of such procedures in migraine are (still) insufficient. But because of its good tolerability, non-invasive nerve stimulation can be tried, if necessary, in patients who refuse medication for migraine prevention.

Home remedies for migraine

Home remedies have their limits. If the discomfort persists for a long time, does not get better or even gets worse, you should always consult a doctor.

Peppermint oil

Herbal medicine and aromatherapy know the following home remedy: Migraine can often be alleviated by dabbing or massaging the temples and/or the aching forehead with a few drops of peppermint oil. The oil has a refreshingly cool effect on the skin, which sufferers often find very pleasant. When applying, however, be careful that none of the essential oil gets into the eyes (irritation of the mucous membranes!).

Peppermint oil applied externally is effective not only for migraines, but also for tension headaches.

Heat and cold applications

If the migraine begins with a feeling of warmth in the head and cold feet and/or hands, a rising arm or foot bath can help, i.e. a partial bath with a slow increase in temperature.

Instead of heat, other migraine patients benefit from cold: A cool compress on the forehead or neck can be very pleasant during an acute attack. Some sufferers also swear by a cold arm or foot immersion bath:

In an arm immersion bath, the arms are immersed in cold water of about 15 degrees for about ten seconds and then warmed up again by rubbing or moving them.
In the foot immersion bath, the feet are held in cold water of about 15 degrees for about 15 to 30 seconds. Then, without drying, put on thick socks and take a walk.

The short immersion bath in cold water reflexively constricts the blood vessels in the arm/foot – and also the arteries in the head, which are painfully dilated during a migraine attack.

Cold immersion baths are not allowed in case of bladder, kidney and abdominal inflammations!

You can also do something against migraine with warm-cold alternating showers.

Tea against migraine

With medicinal herbal teas some people would like to treat their migraine naturally.

Ginger tea can relieve nausea and vomiting that often accompany a migraine attack. To make it, pour a cup of hot water over one teaspoon of coarsely powdered ginger root. Cover and steep for five to ten minutes, then strain. Drink such tea with ginger before meals for migraine-related nausea.

Willow bark tea often proves successful against headaches and migraines, thanks to the salicylates it contains. These are converted in the body into salicylic acids – natural pain-relieving substances similar to artificially produced acetylsalicylic acid (ASA). Here’s how to make the tea: overbrew one teaspoon of finely chopped willow bark (from the pharmacy) with 150 milliliters of boiling water. Allow to steep for 20 minutes and then strain. An alternative to tea are ready-made preparations with willow bark from the pharmacy.

Alternative cures for migraine

Acupuncture against migraine

Acupuncture according to the principles of Traditional Chinese Medicine (TCM) can prevent episodic migraine attacks. In this regard, it can even be considered at least as effective as migraine prophylaxis with medication. According to the current guideline on migraine therapy, this is the result of an evaluation of several studies on the subject.

There are also studies that compared the effect of classical acupuncture with that of sham acupuncture. In fact, placing the fine needles at “real” acupuncture points for migraine prevention proved to be more effective than when the needles were placed in the wrong places or without penetrating the skin. However, the difference was minimal.

According to the guideline, it is not possible to say clearly whether acupuncture is also helpful for chronic migraine based on the current data.

Acupressure for migraine

Suitable acupressure points for migraine are found in the area of the head, face and neck. Seek advice from an experienced therapist regarding self-massage.

Homeopathy for migraine

Many patients hope to get their migraine under control with homeopathy. Depending on the type and severity of the symptoms, homeopaths use various remedies for this purpose, for example:

Iris versicolor: especially for migraine with a pronounced aura and nausea.
Belladonna: especially for throbbing headache with strong nausea and vomiting.
Bryona: when even the slightest touch leads to severe headache
Gelsemium sempervirens: when the pain goes from the back of the head to the eyes.
Sanguinaria: especially for very severe pain
Nux vomica: in case of migraine caused by anger, hecticness and lack of sleep

The homeopathic remedies are available in various forms, such as liquid extracts or globules. Migraine attacks are usually treated with a C30 potency.

From a scientific point of view, however, there is no proof of efficacy: according to guidelines, homeopathy cannot prevent migraine attacks. Some studies on the subject are even said to have produced partly negative results.

Migraine: Schuessler salts

Many sufferers report positive experiences with the use of Schüssler salts. Migraine is said to be treatable with the following Schüssler salts, for example:

No. 7: Magnesium phosphoricum
No. 8: Natrium chloratum
No. 14: Potassium bromatum
No. 21: Zincum chloratum
No. 22: Calcium carbonicum

You can use several Schüssler salts for migraine, but never more than three salts at the same time. For adults with migraines, the recommendation is to take one to three tablets three to six times a day. Children can take half a tablet to two tablets one to three times a day, depending on their height and weight.

The concept of Schüssler salts and their specific efficacy are not clearly proven by studies.

Nutrition in migraine

In almost all migraine patients, an acute attack is triggered by individual trigger factors. For example, some foods can trigger or intensify a migraine attack. Why this is so is largely unclear. In many cases, certain ingredients in the food, so-called biogenic amines such as tyramine and histamine, seem to be responsible. This is because many people report migraine attacks after eating red wine, ripe cheese, chocolate, sauerkraut or bananas – all foods containing biogenic amines.

Cold ice cream can also provoke a migraine attack. However, this does not happen due to certain ingredients in the ice cream, but due to the cold, which irritates certain structures in the brain.

There is no generally valid migraine diet! Because not every patient reacts to histamine, caffeine & Co. with a migraine attack. Therefore, it does not make sense to avoid such frequent food triggers from the outset. It is better to keep a migraine diary to track down your personal migraine triggers.

Migraine diary

It may be possible to identify certain triggers from the records over time: For example, do you notice a cluster of migraine attacks after eating a certain food? Then you should try to avoid it in the future to see if the migraine attacks subsequently become fewer.

Keep in mind, however, that there is usually a few hours, sometimes even a whole day, between eating a food and having an attack. Also, you may not be able to tolerate a particular food only if there are other confounding factors. So evaluating your migraine diary may not be easy. However, your doctor can help you with this.

Also note in the migraine diary if you have used medication (e.g., pain pills) during a migraine attack (type and dosage of the medication) and how it worked. This helps the doctor to plan a suitable therapy.

Pregnant women and nursing mothers with migraine are a special case. What to do with regard to medications? In principle, pregnant women and nursing mothers should use all medications – even over-the-counter ones – only after consulting a doctor. The latter knows best which active ingredients are the least dangerous for the mother and the (unborn) child, taking into account individual risk factors if necessary. Below is some general information.

Medications for migraine attacks

Migraine attacks in the 1st and 2nd trimesters of pregnancy (trimester) can be treated with acetylsalicylic acid (ASA) or ibuprofen, if needed, in consultation with the doctor. In the 3rd trimester, however, both agents are discouraged. Paracetamol should only be taken by pregnant women with migraine if ASA cannot be taken for medical reasons (contraindications). In principle, this analgesic is permitted throughout pregnancy.

Triptans are not approved for use in pregnant women. To date, however, no cases of fetal malformations or other complications have been observed with the use of these specific migraine medications during pregnancy. For sumatriptan, there have been extensive studies in this regard. Therefore, it can be used – as the only representative of the triptans – for migraine attacks during pregnancy if the expected benefit for the mother is greater than a possible risk for the unborn child.

Breastfeeding mothers may also take sumatriptan (as the preferred triptan) for migraine attacks, if appropriate – provided that ASA and ibuprofen (combined with caffeine, if necessary) do not help sufficiently. This is recommended by the Pharmacovigilance and Advisory Center for Embryonic Toxicology of the Berlin Charité (embryotox).

Ergotamines are contraindicated during pregnancy and breastfeeding.

Medications for migraine prevention

The preventive use of magnesium against migraine is not recommended for pregnant women. The reason for this is that magnesium administered directly into a vein (intravenous use) can potentially damage the bones of the unborn child.

There is a lack of sufficient experience regarding the use of Botox for chronic migraine in pregnancy.

In principle, pregnant women with migraine should (also) use non-drug measures to prevent attacks, such as relaxation exercises, biofeedback and acupuncture.