Stop A Migraine Before It Happens

Date: January 1, 2017
Publication: Bottom Line Health

The best options aren’t prescribed often enough…

There are more than 37 million Americans who suffer from migraines, but the odds aren’t in their favor when it comes to drug treatment.

Sobering statistics: Preventive drugs work for only about half of the people who have these awful headaches—and even when the medication does help, migraine frequency is reduced by only about 50%.

The drugs that stop migraines once they’ve started—mainly prescription triptans (such as sumatriptan, rizatriptan and almotriptan) …as well as OTC nonsteroidal anti-inflammatory drugs, such as ibuprofen (Motrin), and Excedrin Migraine, which contains acetaminophen, aspirin and caffeine—are not always effective. They work best when they’re taken soon after the pain begins. Some of the drugs also cause side effects, such as fatigue or gastrointestinal bleeding. And taking them too often can lead to more—and more severe—headaches, known as overuse headaches or “rebound” headaches. So preventive drugs may be needed to avoid overuse of these medications.


Why are migraines so hard to manage? Experts once believed that migraines were mainly caused by the dilation (widening) of blood vessels in the brain. That’s why drugs usually prescribed for other conditions, such as propranolol, a blood pressure drug, have been used to reverse these changes.

But we now believe that migraines have more to do with overstimulation of the trigeminal nerve in the face and head—this can cause blood vessels in the brain to expand and become inflamed. Treatments that affect this nerve (see below) are often very effective.

Important: Everyone who suffers from migraines should pay attention to possible triggers that precipitate attacks. Some people react to strong scents. Others are vulnerable to specific foods (such as bacon, ripened cheeses or alcohol)…food additives such as monosodium glutamate (MSG)…emotional stress…bright lights, etc. Avoiding triggers can be an effective way to prevent some attacks.


Preventing a migraine is always better than trying to treat one that’s already taken hold. Unfortunately, not all doctors are aware of the more recent effective migraine-prevention approaches. Among the best…

Cefaly. Nearly three years ago, the FDA approved the first device for migraine prevention. Cefaly is known as an external trigeminal nerve stimulationunit. It electrically stimulates branches of the trigeminal nerve, which transmits sensations to the face and head.

How it works: The prescription-only device, which blocks pain signals, includes a battery-powered headband with a reusable, self-adhering electrode. Patients position the headband around the forehead, just above the eyes. It may cause a slight tingling, but no pain. It’s used for 20 minutes once a day. Anyone who has an implanted device in the head, a pacemaker or an implanted defibrillator should not use Cefaly.

Scientific evidence: One study found that more than half of migraine patients who used Cefaly were satisfied and intended to keep using it. The unit costs about $350 and is usually not covered by insurance. The device manufacturer offers a 60-day guarantee, so people can get their money back if it doesn’t seem to help.

Biofeedback. Emotional stress is one of the most common migraine triggers. A biofeedback machine allows people to monitor skin temperature, muscle tension, brain waves and other physical stress responses that affect blood flow in the brain. The idea is that once people feel how they react to stress—with tightened forehead muscles, for example—they can modify their reactions with things like deep breathing, muscle relaxation, etc.

Scientific evidence: There’s strong research showing that biofeedback can reduce both the frequency and severity of migraines by 45% to 60%—but only for patients who are willing to practice.

Biofeedback can work about as well as many drugs, but it takes most people a few months before they’re good at it. It can also be costly because you have to work with an instructor at first. To find a certified biofeedback practitioner, go to the website of the Biofeedback Certification International Alliance, Insurance often won’t cover it.

Supplements. Some people do well when they combine one or more of these supplements with the previous approaches…*

Riboflavin, a B vitamin, may improve oxygen metabolism in cells. In one study, migraine frequency was reduced by 50% in patients who took riboflavin (400 mg daily).

Feverfew is an herbal headache remedy. Some research shows that 50 mg to 125 mg daily can help prevent and ease migraines, while other studies suggest that it’s no more effective than a placebo. For some people, it might be a helpful addition to more mainstream treatments.

Magnesium (500 mg daily) can help reduce the frequency of migraines in people with low levels of the mineral.


Known for smoothing facial wrinkles, these injections were FDA-approved for chronic migraines in 2010. Botox is a good treatment option for patients who have 15 or more days of headaches each month.

We still do not know how Botox works to prevent headaches. It probably deactivates pain receptors in the scalp and blocks the transmission of nerve signals between the scalp and the brain.

How it’s done: The drug is injected in multiple locations on the head and neck—and the injections are repeated every three months. It sounds terrible, but the injections are only mildly painful. The procedure takes about 15 minutes, and it’s usually covered by insurance if drugs or other treatments haven’t worked. Botox treatments are given by headache specialists. Side effects may include swallowing problems, blurred vision and speech difficulties.

Important: I advise patients to commit to at least three treatments. If Botox relieves your pain, you and your doctor can decide how frequently you need additional treatments. If you haven’t noticed relief after three treatments, Botox is unlikely to be a good choice for you.

*Check with your doctor before taking these supplements, since they can interact with certain medications and/or cause side effects such as diarrhea.

Source: Mark W. Green, MD,a professor of neurology, anesthesiology and rehabilitation medicine at Icahn School of Medicine at Mount Sinai in New York City, where he directs Headache and Pain Medicine and is the vice chair of Neurology for Professional Development and Alumni Relations. He is coauthor of Managing Your Headaches and several medical textbooks.