In some patients, particularly those with high frequency episodic migraine or chronic migraine, acute medications are not sufficient to control attacks, and medication overuse headache is a constant risk. These patients warrant consideration for migraine medication protection (prophylaxis).
In this situation, several treatment options are available, including injection therapy. Injection therapy is safe and effective in reducing the number of headache days per month in chronic migraine, and it is recommended that this be offered as a treatment option to patients with this condition. In addition, in the very near future, drugs that target the neuropeptide, calcitonin gene related peptide (CGRP), which is associated with migraine pathophysiology, will be an alternative option available to consider.
In general, the most effective medications for treatment of acute attacks are the triptans. Non steroidal anti-inflammatories (NSAIDs) are also important acute medications. Anti-nausea drugs are also helpful if nausea is a significant problem. Opioid medications are best avoided where possible.
Acute Nerve Block (Occipital Nerve Block)
Many patients with headache report that their pain arises from the base of their skull. The pain tends to occur on one side or the other and extends forward to involve the temple, the forehead, the eye or some combination of these sites.
Located in the skull base are the occipital nerves, inflammation/irritation of those nerves may cause a specific type of pain ‘occipital neuralgia’. More commonly however those nerves serve as a site of onset upon which travel the pain signals that produce migraine and other types of headache.
Occipital nerve blocks (ONBs) therefore aim to suppress the pain signal origins of chronic headache.
Important to the management of migraine are behavioural aspects of care, these include:
- Pacing activities to avoid triggering or exacerbating migraine
- Self monitoring to identify factors that influence migraine
- Managing migraine triggers effectively
- Practicing good stress management skills including relaxation techniques
- Having regular meals, good weight management and nutrition
- Exercising regularly
- Reducing caffeine use to no more than 1 cup of coffee per day
- Maintaining healthy sleep habits including regular sleep times and adequate sleep