Acute Migraine: Treating Early

Key to effective management of an acute migraine attack is early recognition and early treatment. Many individuals with migraine who experience an acute migraine headache delay treating that headache because they “wait to see if it’s going to be a migraine.” Unfortunately, by the time the headache builds and blossoms to become full-blown, the treatment they administer is much less likely to be effective. Keep in mind these 2 points: (1) although their specific features may vary, most headaches experienced by an individual with migraine are migraine headaches and will respond to medication intended for the treatment of migraine; and (2) attacks of migraine often possess several distinct phases, and to know the characteristics of these phases may assist in enabling you to recognize an acute attack of migraine for what it is and so initiate treatment earlier than you otherwise would.

A migraine attack may possess as many as 4 distinct phases: a prodrome, an aura, the headache phase itself, and a postdrome. Prodromal symptoms tend to be rather non-specific, and the most common of those symptoms are listed in the accompanying Box. The realization that you are experiencing a prodrome can be vital to achieving success in rapidly terminating an attack of migraine; by definition, prodromal symptoms always occur prior to the headache phase, and their occurrence should serve as a signal that it’s time to make ready the weapons you have available for acute migraine treatment.

Common Prodromal Symptoms

• Repetitive yawning

• Fatigue

• Euphoria/excessive energy

• Restlessness

• Irritability

• Anxiety

• Food cravings

• Difficulty concentrating

• Sensitivity to light or sound

Whereas the majority of individuals with migraine experience a prodrome, only 20-25% will ever experience aura symptoms. An aura consists of a specific set of neurologic symptoms (most often visual) that typically last around 15 minutes and may occur immediately prior to the headache phase or – somewhat less often – after the headache phase has begun.

As indicated previously, the headache itself may range in intensity from quite mild to severe and incapacitating. It may or may not be lateralized to one side of the head or involve pain that throbs. It may or may not be accompanied by light sensitivity, sound sensitivity, or nausea. Even in a given individual, migraine headaches rarely are stereotyped; instead, their characteristics differ from attack to attack.

The headaches phase often is followed by a postdrome, the final phase of a migraine attack wherein the headache itself has largely or entirely subsided… but, even so, you may be left feeling drained, exhausted, and “hung over.” The best means of dealing with postdromal symptoms is to avoid their occurrence altogether by treating the migraine attack aggressively . . . and to treat aggressively calls for early intervention.

If your choice for acute migraine treatment includes a medication, you should know that its effectiveness is a function of how rapidly the peak blood level of that medication is achieved following administration and when in the course of a migraine attack the medication is administered. Consider also a related point that cannot be overemphasized: an acute migraine headache is a dynamic biologic process, and as the headache evolves its susceptibility to treatment decreases. Three aspirin and a caffeinated beverage taken early may prove far more effective in terminating an attack than an injectable medication administered when the headache is fully developed. The oral triptans, medications developed specifically for acute migraine treatment, are far more effective – and consistently effective – if taken when the headache is still early/mild to moderate in intensity rather than later/moderate to severe in intensity. Delaying administration increases the chance of an incomplete treatment response, and incomplete headache relief correlates highly with early recurrence of moderate to severe head pain. Treat early!

John F. Rothrock, MD

Editor-in-Chief, Headache

Professor and Vice Chair Director,

Headache Treatment and Research Program

University of Alabama at Birmingham

Birmingham, AL, USA