Five worst treatments for migraines

About 36 million Americans suffer from excruciating migraine headaches, and many get low-value treatments from their doctors such as unnecessary imaging scans or prescription opiate painkillers that can be addictive. For this reason, the American Headache Society decided to compile a list of the five worst practices when it comes to managing migraines that was recently published in the journal Headache.

It’s part of new campaign kicked off last year by the American Board of Internal Medicine that’s designed to get doctors to spare patients from needless treatments or medical tests that cause more harm than good.

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“We appealed to our members to submit to us a list of procedures, tests, and treatments that could sometimes be more harmful than helpful to patients,” said Brigham and Women’s Hospital internist Dr. Elizabeth Loder, president of the American Headache Society. The medical group represents healthcare providers who treat headaches, and it is partially funded by pharmaceutical and device manufacturers.

Here are the top five don’ts.

1. Don’t rely too heavily on over-the-counter medications. While over-the-counter pain relievers such as aspirin or ibuprofen work fine to relieve the occasional migraine, they could lead to “medication overuse headaches” if taken as often as two to three days a week, said Loder who is chief of the division of headache and pain in department of neurology at the Brigham. This is particularly the case with pain relievers like Excedrin that contain caffeine, or generic pain relievers that contain both acetaminophen, aspirin, and caffeine.

“We recommend having a conversation with your doctor if you’re treating headaches a few days a week,” Loder said. Certain prescription treatments, such as anti-seizure medications or drugs for high blood pressure, can be taken daily as a preventive. For those who don’t want to take a daily medication, she added, making an effort to get 7 to 8 hours of sleep a night and trying relaxation strategies like meditation can also help reduce headaches.

2. Don’t get a brain scan if headaches haven’t changed much over time. Since patients with chronic migraines aren’t at any greater risk of having, say, a brain tumor or embolism, the new recommendations state that there’s no reason to monitor their condition with imaging scans.

“A sudden new onset of chronic migraines might call for an imaging scan,” Loder said. “But we usually find these scans don’t alter the course of treatment, which is why we don’t recommended them for someone with characteristic migraine symptoms who has a family history.” Such migraine symptoms include pain on one or both sides of the head that may have a pulsating or throbbing quality; nausea and vomiting; blurred vision; visual phenomenon like bright spots of flashes of lights (aura); lightheadedness; sensitivity to noise and light.

3. Don’t get a CT scan if an imaging scan is needed. The computed tomography (CT) scan delivers a significant amount of radiation that can raise future cancer risks. A magnetic resonance imaging (MRI) scan is preferred because it doesn’t use radiation. The one time CT scans are useful for head pain, Loder said, is when doctors are concerned about bleeding in the brain.

4. Don’t consider migraine surgery to be a proven cure. Surgeries to relieve migraines are still experimental and should only be done in a research setting, according to the new recommendations.

“There’s been a real increase in the number of surgical procedures being offered to relieve migraines, but we’d like to not see these procedures enter widespread practice until they’ve been adequately tested,” Loder said. “We’ve seen some early encouraging results, but they’re still preliminary.”

Surgeons started performing procedures to slice into facial nerves and muscles deemed to be “migraine trigger points” after some patients undergoing cosmetic brow lifts noticed an improvement in their migraines after the surgery.

Large studies to determine which surgical procedures, if any, are effective are still lacking, and Loder warns that, unlike medication treatments, the surgeries are often irreversible; this could mean lifelong problems for patients who experience a worsening of their headaches after surgery.

5. Don’t use opiate or butalbital drugs as a first-line therapy. Avoiding addictive painkillers should be obvious to most doctors prescribing drugs for migraines, but the American Headache Society emphasized recent warnings by the US Food and Drug Administration for doctors to curtail their prescriptions of habit-forming drugs for chronic pain—except for patients with terminal cancer.

Opiates combined with acetaminophen—Vicodin and Percocet—and butalbital—a barbituate that’s combined with acetaminophen, aspirin, or caffeine (Fioricet, Fiorinal)—have been shown in research to increase the frequency of migraines when used regularly to treat them. They may also increase a person’s sensitivity to pain, making the headaches worse.