What are the causes and treatments of migraines (episodic headaches with neurological symptoms)?

From the Guidelines

Migraines should be treated with a multi-faceted approach, starting with acute treatment using over-the-counter medications like ibuprofen (400-600mg) or naproxen (500mg), and considering preventive medications such as beta blockers, topiramate, or candesartan for frequent migraines. For acute migraine treatment, the most consistent evidence exists for aspirin, ibuprofen, naproxen sodium, tolfenamic acid, and the combination agent acetaminophen plus aspirin plus caffeine 1. If these aren't effective, prescription triptans such as sumatriptan (50-100mg) can provide relief 1.

Key Considerations for Treatment

• For patients whose migraine attack has not responded to NSAIDs, use migraine-specific agents (triptans, DHE) 1
• Select a nonoral route of administration for patients whose migraines present early with nausea or vomiting as a significant component of the symptom complex, and treat nausea and vomiting with an antiemetic 1
• Migraine sufferers should be evaluated for use of preventive therapy, especially if they experience two or more attacks per month that produce disability lasting 3 or more days per month 1

Preventive Treatment

• Consider preventive treatment in patients who are adversely affected by migraine on ≥2 days per month despite optimized acute treatment 1
• Use beta blockers (atenolol, bisoprolol, metoprolol or propranolol), topiramate or candesartan as first-line medications 1
• Consider CGRP monoclonal antibodies as third-line medications for difficult cases 1

Lifestyle Modifications

• Identify and avoid personal triggers (common ones include certain foods, stress, irregular sleep, and hormonal changes)
• Maintain regular sleep patterns
• Stay hydrated
• Practice stress management techniques like meditation

Migraines involve complex neurological processes including trigeminal nerve activation and cerebral blood vessel changes, which is why a multi-faceted approach combining medication and lifestyle changes typically works best for management.

From the FDA Drug Label

Sumatriptan presumably exerts its therapeutic effects in the treatment of migraine headache through agonist effects at the 5-HT1B/1D receptors on intracranial blood vessels and sensory nerves of the trigeminal system, which result in cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release.

The causes of migraines are not directly addressed in the provided drug labels. The treatments of migraines mentioned include sumatriptan, which is believed to work by constricting cranial vessels and inhibiting pro-inflammatory neuropeptide release through its effects on 5-HT1B/1D receptors 2.

Key points to consider when treating migraines with sumatriptan include:

• Monitoring blood pressure due to the risk of significant elevation, including hypertensive crisis 2 2
• Avoiding use in patients with uncontrolled hypertension, CAD, or a history of stroke or TIA 2
• Being aware of the potential for medication overuse headache and serotonin syndrome 2

From the Research

Causes of Migraines

• Migraines are a chronic neurological condition with episodic exacerbations, characterized by recurrent attacks of moderate to severe throbbing headache, typically unilateral, exacerbated by physical activity, and associated with phonophobia, photophobia, nausea, and vomiting 3
• The overarching hypothesis of migraine pathophysiology describes migraine as a disorder of the pain modulating system, caused by disruptions of the normal neural networks of the head 3
• The activation of vascular networks results in meningeal vasodilation and inflammation, which is perceived as head pain 3

Treatments of Migraines

• Preventive medication therapy reduces migraine frequency, severity, and headache-related distress, and may also improve quality of life and prevent the progression to chronic migraines 4
• First-line medications established as effective based on clinical evidence include divalproex, topiramate, metoprolol, propranolol, and timolol 4
• Medications such as amitriptyline, venlafaxine, atenolol, and nadolol are probably effective but should be second-line therapy 4
• Acetaminophen, nonsteroidal anti-inflammatory drugs, triptans, antiemetics, ergot alkaloids, and combination analgesics have evidence supporting their effectiveness in the treatment of migraine 5
• Over-the-counter medications, such as acetaminophen, ibuprofen, naproxen, and aspirin, are considered a first-line therapy for most migraineurs and have shown strong efficacy when used as first-line treatments for mild-to-moderate migraine attacks 3
• Monoclonal antibodies against calcitonin gene-related peptide (CGRP) or the CGRP receptor can be used if other drugs are not effective, are not tolerated or contraindicated 6

Non-Pharmacologic Therapies

• Identifying and managing environmental, dietary, and behavioral triggers are useful strategies for preventing migraines 4
• Nonpharmacologic therapies such as relaxation training, thermal biofeedback combined with relaxation training, electromyographic feedback, and cognitive behavior therapy also have good evidence to support their use in migraine prevention 4
• Lifestyle modifications and non-pharmacological therapies are important components of migraine management 7