Migraine Today: Evidence-Based Answers to Patients' Most Important Questions

This article presents the most important and practical questions and answers that every migraine patient would like to know. It is based on one of the most authoritative modern publications on the subject — "Migraine: integrated approaches to clinical management and emerging treatments," published in The Lancet (Vol. 397, April 17, 2021), with lead author Professor Messoud Ashina from the Danish Headache Center at the University of Copenhagen, along with contributions from an international team of neurologists, psychologists, and researchers from leading global institutions. The publication summarizes the latest scientific findings, international guidelines, and clinical experience, focusing on integrated, personalized approaches to migraine treatment, including pharmaceutical, non-pharmaceutical, and new therapeutic options.

Expert Insights

1. Migraine is a leading cause of years lived with disability — why should society take this seriously?

Quote: "Migraine is a highly disabling neurological disorder that affects over 1 billion people worldwide... Migraine is the leading cause of years lived with disability in people under the age of 50."

Explanation: Migraine is not just a headache — it is a chronic neurological condition with a major impact on quality of life, productivity, and mental health. This should motivate both patients and institutions to seek effective, modern care rather than downplay the problem.

2. Modern therapies: Why is an individualized approach crucial?

Quote: "Every effective therapeutic strategy begins with developing a treatment plan tailored to the patient's individual clinical characteristics, preferences, and needs."

Explanation: There is no "one-size-fits-all" solution for migraine. The medical team must consider the frequency and severity of attacks, associated symptoms, past medication experiences, and even the patient’s lifestyle and preferences. For example, some patients do well with NSAIDs (nonsteroidal anti-inflammatory drugs), others require specific medications like triptans, and some benefit most from new therapies like monoclonal antibodies.

3. How can we prevent chronification and "medication overuse headache"?

Quote: "Overuse of acute treatment medications is a major risk factor for progression to chronic migraine... The highest risk is associated with triptans, opioids, and barbiturates, while NSAIDs have a lower risk."

Explanation: Patients should be aware that frequent use of painkillers (especially more than 10–15 days per month) can lead to what is known as "medication overuse headache," which worsens the condition. Therefore, education, controlled treatment, and discussing preventive options with a doctor are strongly recommended.

4. Beyond medication: What does modern comprehensive migraine therapy include?

Quote: "There are several non-pharmacological therapies with proven benefit in migraine... Cognitive behavioral therapy, biofeedback, and relaxation techniques are the most strongly supported, along with certain neuromodulation devices."

Explanation: Migraine treatment is most effective when it includes a combination of pharmaceutical and non-pharmaceutical approaches — such as psychotherapy, stress management, physical therapy, sufficient sleep, and appropriate physical activity. New technologies like non-invasive neuromodulation also show promising results, especially for patients who cannot tolerate or do not respond to medication.

5. The importance of follow-up, education, and communication with the medical team

Quote: "Patient education is essential for long-term treatment success... Regular follow-up and discussion of expectations and satisfaction with treatment are important."

Explanation: Patients and their loved ones should know that being informed and actively participating in the treatment process, maintaining frequent communication with their physician, and having realistic expectations are key to managing the condition. A "partnership" between doctor and patient should be established.

Questions and Answers

1. What are the main types of migraine medications, and when are they used?

Answer: There are two main types of migraine medications: acute treatments (used during an attack) and preventive medications (used to reduce the frequency and severity of attacks). Acute treatments include over-the-counter pain relievers (such as acetaminophen and NSAIDs — ibuprofen, aspirin, diclofenac), specific anti-migraine drugs like triptans, and new medication classes — gepants and ditans. Preventive therapy includes medications taken daily or regularly to reduce the number and intensity of attacks (e.g., beta-blockers, anti-epileptics, certain antidepressants, monoclonal antibodies, and others).

2. How do I know which medication is right for me?

Answer: The choice of medication depends on the severity and frequency of attacks, accompanying symptoms (nausea, vomiting, sensitivity to light and sound), other health issues, past reactions to medications, and personal preferences. Clinical guidelines recommend starting with simple analgesics for milder cases and moving on to specific drugs (triptans, gepants, ditans) if those don't help. For chronic or very severe migraine, a consultation with a specialist is appropriate to consider preventive therapy.

3. What new therapies have recently emerged, and when are they used?

Answer: In recent years, new classes of drugs have been developed: gepants (such as ubrogepant and rimegepant) and ditans (lasmiditan) — designed specifically for acute treatment and used when other medications are ineffective or contraindicated. There are also monoclonal antibodies (e.g., erenumab, galcanezumab) used for prevention, especially when other prophylactic options are ineffective or poorly tolerated. These new therapies are important alternatives for difficult cases, though access is sometimes limited due to cost and regulations.

4. Does timing matter when taking migraine medication?

Answer: Yes! For best results, acute migraine medications (like triptans) should be taken as early as possible — at the onset of the attack, when the pain is still mild to moderate. This significantly increases the chance of complete pain relief within two hours. If you experience nausea or vomiting, antiemetics (anti-nausea drugs) can be used, or a non-oral form of administration (such as a spray or injection) may be chosen.

5. What are the non-pharmaceutical methods, and is there evidence of their effectiveness?

Answer: Non-pharmaceutical approaches include cognitive behavioral therapy (CBT), relaxation techniques, biofeedback, good sleep hygiene, stress avoidance, physical therapy, and certain neuromodulation devices (e.g., magnetic or nerve stimulation). According to the article, there is strong scientific evidence supporting behavioral therapies (CBT, biofeedback) and neuromodulation devices as complementary or alternative options, especially for individuals who cannot tolerate medications, have contraindications, or prefer more natural solutions. For diets and supplements, evidence is limited, and indiscriminate food elimination without medical consultation is not recommended.

Conclusion

In conclusion, the Lancet publication emphasizes that modern migraine treatment requires a personalized, comprehensive approach that combines scientifically proven pharmaceutical and non-pharmaceutical therapies tailored to each patient's needs, preferences, and medical background. Crucial to successful management are timely specialist consultations, appropriate medication choices and usage, patient education and engagement, and active follow-up and communication with the medical team. New therapeutic options offer hope for patients for whom standard treatments have failed. To achieve optimal migraine control, it’s essential to apply the most up-to-date scientific knowledge — exactly what this international expert review provides.

Source: Ashina M, Buse DC, Ashina H, Pozo-Rosich P, Peres MFP, Lee MJ, Terwindt GM, Halker Singh R, Tassorelli C, Do TP, Mitsikostas DD, Dodick DW. Migraine: integrated approaches to clinical management and emerging treatments. The Lancet, Vol. 397, April 17, 2021, pp. 1505–1515. DOI: 10.1016/S0140‑6736(20)32342‑4