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What is Migraine and How to Treat it ?

What are migraines?

Migraines are a recurring type of headache. They cause moderate to severe pain that is throbbing or pulsing. The pain is often on one side of your head. You may also have other symptoms, such as nausea and weakness. You may be sensitive to light and sound.

What causes migraines?

Researchers believe that migraine has a genetic cause. There are also a number of factors that can trigger a migraine. These factors vary from person to person, and they include

Stress
Anxiety
Hormonal changes in women
Bright or flashing lights
Loud noises
Strong smells
Medicines
Too much or not enough sleep
Sudden changes in weather or environment
Overexertion (too much physical activity)
Tobacco
Caffeine or caffeine withdrawal
Skipped meals
Medication overuse (taking medicine for migraines too often)

Some people have found that certain foods or ingredients can trigger headaches, especially when they are combined with other triggers. These foods and ingredients include

Alcohol
Chocolate
Aged cheeses
Monosodium glutamate (MSG)
Some fruits and nuts
Fermented or pickled goods
Yeast
Cured or processed meats

Who is at risk for migraines?

About 12% of Americans get migraines. They can affect anyone, but you are more likely to have them if you

Are a woman. Women are three times more likely than men to get migraines.
Have a family history of migraines. Most people with migraines have family members who have migraines.
Have other medical conditions, such as depression, anxiety, bipolar disorder, sleep disorders, and epilepsy.

What are the symptoms of migraines?

There are four different phases of migraines. You may not always go through every phase each time you have a migraine.

Prodome. This phase starts up to 24 hours before you get the migraine. You have early signs and symptoms, such as food cravings, unexplained mood changes, uncontrollable yawning, fluid retention, and increased urination.
Aura. If you have this phase, you might see flashing or bright lights or zig-zag lines. You may have muscle weakness or feel like you are being touched or grabbed. An aura can happen just before or during a migraine.
Headache. A migraine usually starts gradually and then becomes more severe. It typically causes throbbing or pulsing pain, which is often on one side of your head. But sometimes you can have a migraine without a headache. Other migraine symptoms may include
- Increased sensitivity to light, noise, and odors
- Nausea and vomiting
- Worsened pain when you move, cough, or sneeze
Postdrome (following the headache). You may feel exhausted, weak, and confused after a migraine. This can last up to a day.

Migraines are more common in the morning; people often wake up with them. Some people have migraines at predictable times, such as before menstruation or on weekends following a stressful week of work.

What is the Triggers of Migraine ?

Some common migraine triggers include:

Hormone changes. Many women notice that they have headaches around their period, while they’re pregnant, or when they’re ovulating. Symptoms may also be tied to menopause, birth control that uses hormones, or hormone replacement therapy.
Stress. When you’re stressed, your brain releases chemicals that can cause blood vessel changes that might lead to a migraine.
Foods. Some foods and drinks, such as aged cheese, alcohol, and food additives like nitrates (in pepperoni, hot dogs, and lunchmeats) and monosodium glutamate (MSG), may be responsible in some people.
Skipping meals
Caffeine. Getting too much or not getting as much as you’re used to can cause headaches. Caffeine itself can be a treatment for acute migraine attacks.
Changes in weather. Storm fronts, changes in barometric pressure, strong winds, or changes in altitude can all trigger a migraine.
Senses. Loud noises, bright lights, and strong smells can set off a migraine.
Medications. Vasodilators, which widen your blood vessels, can trigger them.
Physical activity. This includes exercise and sex.
Tobacco
Changes to your sleep. You might get headaches when you sleep too much or not enough.

What is Migraine Types ?

Migraine can be classified into subtypes, according to the headache classification committee of the International Headache Society:

Migraine without aura is a recurrent headache attack of 4 to 72 hours; typically unilateral in location, pulsating in quality, moderate to severe in intensity, aggravated by physical activity, and associated with nausea and light and sound sensitivity (photophobia and phonophobia).
Migraine with aura has recurrent fully reversible attacks, lasting minutes, typically one or more of these unilateral symptoms: visual, sensory, speech and language, motor, brainstem, and retinal, usually followed by headache and migraine symptoms.
Chronic migraine is a headache that occurs on 15 or more days in a month for more than three months and has migraine features on at least eight or more days in a month.
Complications of migraine
- Status migrainosus is a debilitating migraine attack that lasts more than 72 hours.
- Persistent aura without infarction is an aura that persists for more than one week without evidence of infarction on neuroimaging.
- Migrainous infarction is one or more aura symptoms associated with brain ischemia on neuroimaging during a typical migraine attack.
- Migraine aura-triggered seizure occurs during an attack of migraine with aura, and a seizure is triggered.

Probable migraine is a symptomatic migraine attack that lacks one of the features required to fulfill criteria for one of the above and does not meet the criteria for another type of headache.

Episodic syndromes that may be associated with migraine

Recurrent gastrointestinal disturbances are recurrent attacks of abdominal pain and discomfort, nausea, and vomiting that may be associated with migraines.
Benign paroxysmal vertigo has brief recurrent attacks of vertigo.
Benign paroxysmal torticollis is recurrent episodes of head tilt to one side.

How are migraines diagnosed?

For migraines without aura, diagnostic criteria include:

5+ attacks fulfilling the other criteria
Headache attacks that last from 4 to 72 hours (untreated or unsuccessfully treated)
Headache consisting of at least 2 of the following characteristics: unilateral location, pulsating quality, moderate/severe pain intensity, and aggravation by or causing avoidance of routine physical activity (i.e., walking or climbing stairs)
During the headache, the presence of at least one of the following: nausea/vomiting, photophobia/phonophobia
Not better accounted for with another ICHD-3 diagnosis

For migraines with aura, diagnostic criteria include:

Two or more attacks fulfilling the other criteria
At least one of the following completely reversible symptoms of aura: visual, sensory, motor, speech or language, brainstem, retinal
At a minimum of three of the following six characteristics: 1+ one aura symptoms spread gradually over greater than equal to 5 minutes, 2+ aura symptoms occur in succession, each aura symptom lasts 5-60 minutes, 1+ aura symptom is unilateral, 1+ aura symptom is positive, the aura is accompanied or followed within 60 minutes by the headache
Not better accounted for with another ICHD-3 diagnosis

For chronic migraine, diagnostic criteria include:

Headache (migraine-like or tension-type-like) on greater than or equal to 15 days/month for greater than three months and also fulfilling criteria B and C
Occurring in a patient who has experienced at least five attacks fulfilling criteria B through D for migraine presenting without aura and/or criteria B and C for migraine that presents with aura
Occurs greater than or equal to 8 days/month for greater than three months, fulfilling any of the following
Criteria C and D for migraine without aura
Criteria B and C for migraine with aura
Believed by the patient to be migraine at the point of onset and relieved by a triptan or ergot derivative
Not better accounted for with another ICHD-3 diagnosis

How are migraines treated?

There is no cure for migraines. Treatment focuses on relieving symptoms and preventing additional attacks.

There are different types of medicines to relieve symptoms. They include triptan drugs, ergotamine drugs, and pain relievers. The sooner you take the medicine, the more effective it is.

There are also other things you can do to feel better:

Resting with your eyes closed in a quiet, darkened room
Placing a cool cloth or ice pack on your forehead
Drinking fluids

There are some lifestyle changes you can make to prevent migraines:

Stress management strategies, such as exercise, relaxation techniques, and biofeedback, may reduce the number and severity of migraines. Biofeedback uses electronic devices to teach you to control certain body functions, such as your heartbeat, blood pressure, and muscle tension.
Make a log of what seems to trigger your migraines. You can learn what you need to avoid, such as certain foods and medicines. It also help you figure out what you should do, such as establishing a consistent sleep schedule and eating regular meals.
Hormone therapy may help some women whose migraines seem to be linked to their menstrual cycle
If you have obesity, losing weight may also be helpful

If you have frequent or severe migraines, you may need to take medicines to prevent further attacks. Talk with your health care provider about which drug would be right for you.

Certain natural treatments, such as riboflavin (vitamin B2) and coenzyme Q10, may help prevent migraines. If your magnesium level is low, you can try taking magnesium. There is also an herb, butterbur, which some people take to prevent migraines. But butterbur may not be safe for long-term use. Always check with your health care provider before taking any supplements.

What is the Medicines for Migraine ?

1) Abortive Treatments

1.Anti-inflammatories (NSAIDs and Acetaminophen)

Non-steroidal anti-inflammatory drugs (NSAIDs) are mainstay choices and have the greatest strength of evidence. Ibuprofen, naproxen sodium, acetylsalicylic acid (ASA), and diclofenac potassium all have double-blinded randomized controlled trial evidence for efficacy that has analysis in systematic reviews.

NSAIDs include aspirin, naproxen, ibuprofen, tolfenamic acid, diclofenac, piroxicam, ketoprofen, and ketorolac.

Acetaminophen and the combination of acetaminophen/aspirin/caffeine have also demonstrated consistent evidence of efficacy for acute migraine.

Mechanism of Action

NSAIDs inhibit prostaglandin synthesis. NSAIDs reversibly inhibit cyclooxygenase (COX) 1 and 2. The NSAIDs that inhibit prostaglandin E2 synthesis are effective in treating acute migraine attacks. Aspirin acts as an irreversible COX I and 2 inhibitor.

Although not entirely understood, the current thought is that acetaminophen affects central processes, such as positive effects on the serotonergic descending inhibitory pathways. It also may affect opioidergic systems, eicosanoid systems, and the nitric oxide-containing pathways.

Administration

Aspirin: Peroral (PO) tablet with standard dosages of 325 mg, 500 mg, and 400 mg effervescent; treatment dosage of up to 1000 mg
Naproxen: PO tablet with standard dosages of 220 mg, 275 mg, 500 mg, and 550 mg; treatment dosage of 550 to 1100 mg per day in divided dosages
Ibuprofen: PO tablet with standard dosages of 200 mg, 400 mg, 600 mg, and 800 mg; treatment dosage of 200 to 800 mg
Tolfenamic acid: PO tablet with standard and treatment dosage of 200 mg
Diclofenac: PO tablet with standard dosages of 50 mg; treatment dosage of 50 to 100 mg
Piroxicam: PO capsules with standard dosages of 10 mg, 20 mg; treatment dosage of 40 mg
Ketorolac: Parenteral dosing with standard dosages of 30 to 60 mg; treatment dose of 30 to 60 mg

Adverse Effects

The most common adverse effects of NSAIDs are GI symptoms, which include dyspepsia, abdominal burning or discomfort, and diarrhea. Other less common symptoms include easy bruising, pruritus, rash, hypersensitivity response in asthmatics, gastritis, esophagitis, GI bleeding, renal failure, hepatic impairment, and cardiovascular events.

Besides allergic reactions, no serious side effects have been observed with acetaminophen when taken in appropriate dosages. After higher doses or prolonged duration of taking acetaminophen, hepatotoxicity, and nephrotoxicity (less common) can occur.

Contraindications

In addition to NSAID hypersensitivity reaction, another agreed-upon absolute contraindication is for those in the preoperative period of coronary artery bypass graft surgery. Warnings include those with significant cardiovascular disease, renal insufficiency, gastrointestinal erosive disorders, bleeding diathesis, and those taking warfarin.

For acetaminophen, contraindications include hypersensitivity reactions and severe active liver disease.

2.Triptans

Seven triptans have approval from the FDA and marketed for acute treatment of migraines They include sumatriptan, eletriptan, naratriptan, zolmitriptan, rizatriptan, frovatriptan, and almotriptan. Triptans are significantly more expensive than NSAIDs as a class. They are often therapeutic choices if other therapies have failed (i.e., NSAID, acetaminophen) or if the headache is severe.

Mechanism of Action

Triptans are serotonin-receptor agonists with a high affinity for 5-HT1B and 5-HT1D receptors, and variable affinity for 5-HT1F receptors. The proposed mechanism of action involves binding postsynaptic 5-HT1B receptors on the smooth muscle cells of blood vessels and presynaptic 5-HT1D receptors on the trigeminal nerve terminals and dorsal horn neurons.

Administration

Sumatriptan: PO tablet with standard dosages of 100, 50, and 25 mg; also available parenteral (though IV contraindicated because of its potential to cause vasospasm)

Eletriptan: PO tablet with standard dosages of 40 and 20 mg; contraindicated in patients with renal failure, arrhythmias, and heart failure

Naratriptan: PO tablet with standard dosages of 2.5 and 1 mg; has a sulfa group

Zolmitriptan: PO tablet with standard dosages of 5 and 2.5 mg; also available as wafer and nasal spray; wafer contains phenylalanine

Rizatriptan: PO tablet with standard dosages of 10 and 5 mg; also available as a wafer; wafer contains phenylalanine

Frovatriptan: PO tablet with a standard dose of 2.5 mg

Almotriptan: PO tablet with standard dosages of 12.5 and 6.25 mg; has a sulfa group

Adverse Effects

The most common adverse effects of triptans include pressure or tightness sensations of the chest, throat, or jaw; limb heaviness; myalgias; and fatigue. Less common adverse effects include flushing, paresthesias, dizziness, asthenia, and mental cloudiness.

Contraindications

Triptans have associations with increased blood pressure, and providers should avoid giving them to patients with uncontrolled hypertension, ischemic cardiac syndrome, cerebrovascular syndrome, or peripheral vascular condition. Patients should also not take them within 24 hours of administration, another triptan, or ergot-type medication. Triptans are also contraindicated in hemiplegic or basilar migraine and patients with hepatic impairment.

3.Antiemetics

When a migraine is associated with nausea/vomiting, an antiemetic is an excellent choice for treatment. The administration of an antiemetic is often in combination with either an NSAID or triptan, but can be used as monotherapy. Two common antiemetics used include metoclopramide and prochlorperazine. Metoclopramide has the greatest evidence for efficacy in migraine and is associated with a less likelihood of extrapyramidal side effects than prochlorperazine, but both are good initial options. Domperidone, promethazine, chlorpromazine are other examples of antiemetics.

Mechanism of Action

Metoclopramide is a benzamide that antagonizes the D2 receptor at lower doses and 5HT-3 at higher doses.

Prochlorperazine and chlorpromazine are dopamine antagonists (D2 receptor), providing antiemetic and migraine relief effects.

Administration

Metoclopramide: PO and parenteral formulations available; treatment dosages of 10 – 20 mg

Prochlorperazine: PO, parenteral and rectal formulations available; treatment dosage of 10 mg (PO and parenteral) and 25 mg (rectal)

Chlorpromazine: PO and parenteral formulations available; treatment dosage of 0.1 mg/kg up to 25 mg

Adverse Effects

Most antiemetics used for migraines are associated with a risk of QT interval prolongation and torsades de pointes. Metoclopramide, prochlorperazine, and chlorpromazine can cause dystonia, tardive dyskinesia, and akathisia (collectively known as extrapyramidal symptoms). Coadministration with diphenhydramine can prevent these symptoms. Other side effects are uncommon and can include headaches and allergic reactions such as anaphylaxis.

Contraindications

Considering the dopamine antagonists, contraindications include known hypersensitivity reactions and know extrapyramidal symptom reactions.

4.Ergotamines

Triptans have largely replaced ergotamines, as studies have shown more efficacy for triptans. Dihydroergotamine has demonstrated some efficacy, while the effectiveness of ergotamine is uncertain. In one systematic review, dihydroergotamine was not as effective as triptans, but when combined with an antiemetic, was found to be as effective as ketorolac, opiates, or valproate. Dihydroergotamine may be a useful option when patients do not respond to other medications, including triptans.

Mechanism of Action

Ergotamines, like triptans, are potent 5-HT 1b/1d receptor agonists. They involve constricting the theorized pain-producing intracranial extracerebral blood vessels at the 5-HT1B receptors and inhibit the trigeminal neurotransmission at both peripheral and central 5-HT1D receptors. They also interact with other serotonin, adrenergic, and dopamine receptors. They cause constriction of peripheral and cranial blood vessels.

Administration

Dihydroergotamine: Parenteral dosing with dosages between 0.5 – 1 mg; intranasal formulation available (4 mg)

Adverse Effects

The most common side effects include nausea and vomiting. Administer with an antiemetic. Dysphoria is another observed side effect (central 5-HT1A agonism).

Contraindications

Similar to triptans, those with cardiovascular disease should avoid the use of ergotamines. The peripheral vascular constrictive effects of ergotamines are more pronounced than triptans since triptans do not have activity at adrenergic and 5-HT2A receptors.

2)Preventive Treatments

1.Beta-Blockers

Propranolol, timolol, bisoprolol, metoprolol, atenolol, and nadolol have shown positive outcomes in migraine prevention studies. Beta-blockers with intrinsic sympathomimetic activity (such as acebutolol, alprenolol, oxprenolol, and pindolol) are not effective for migraine prevention.

Administration

Propranolol: PO immediate-release and long-acting formulations available; dose for immediate release ranging from 80 to 240 mg/day divided every 6 to 8 hours; dose for long-acting release is 80 to 240 mg/day

Timolol: PO formulation with doses of 20-30 mg/day

Bisoprolol: PO formulation with doses of 2.5 to 10 mg/day

Metoprolol: PO formulation with doses of 50 to 200 mg/day twice daily

Atenolol: PO formulation with doses of 50 to 200 mg/day

Nadolol: PO formulation with doses of 40 to 240 mg/day

Mechanism of Action

The mechanisms of action of beta-blockers in migraine prevention are not entirely understood. The thinking is that the beta-1 mediated effects could inhibit noradrenaline release and tyrosine hydroxylase activity, accounting for prophylactic action. Other possibilities include serotonergic blockade, inhibiting thalamic activity, and nitrous oxide blockade.

Adverse Effects

Common adverse effects include drowsiness, fatigue, dizziness, and weakness. Other adverse effects include weight gain, symptomatic hypotension, nausea/vomiting, diarrhea, feelings of coldness in extremities, and dry skin/mouth/eyes, bradycardia, bronchospasm, dyspnea, alopecia, visual disturbances, insomnia, sexual dysfunction, and metabolism alterations.

Contraindications

Asthma and chronic obstructive pulmonary disease have been classic contraindications because of the potential for beta-blockers to cause bronchospasm. Cocaine intoxication is another contraindication because of the risk of coronary vasospasm. This contraindication is subject to debate.

2.Antiepileptics

Several antiepileptic drugs (AEDs) have been studied and proven effective for migraine prevention, with topiramate and valproate having the best evidence.[10]

Administration

Topiramate: PO formulation with doses of 25-200 mg/day

Valproate: PO formulation of extended (once daily) and delayed (2 divided doses daily) releases are available; doses of 500-1500 mg/day

Mechanism of Action

Similar to the beta-blockers, it is unclear what effect antiepileptics have on migraine prevention. For topiramate, it blocks multiple channels such as voltage-dependent sodium and calcium channels. It also has been shown to inhibit glutamate-mediated excitatory neurotransmission, facilitate GABA-A-mediated inhibition, inhibit carbonic anhydrase activity, and reduce CGRP secretion from trigeminal neurons. For valproate, similar to topiramate, multiple mechanisms may contribute to migraine prevention. They include enhancing GABAergic inhibition, blocking excitatory ion channels, and downregulating the expression of CGRP in brain tissue.

Adverse Effects

Common adverse effects of topiramate include nausea/vomiting, diarrhea, somnolence, dizziness, weight loss, paresthesias, fatigue, nasopharyngitis, and weight loss. Other adverse effects include tachypnea, palpitations, bleeding, mood changes, dysuria, hematuria, and increased frequency of urination.

Common adverse effects of valproate include nausea/vomiting, diarrhea, abdominal pain, headache, drowsiness, hair loss, tremors, dizziness, visual disturbances, tinnitus, changes in appetite, and weight gain. Other adverse effects include confusion, severe drowsiness, bleeding, and inflammation.

Contraindications

Hypersensitivity to topiramate is a contraindication to the drug.

Contraindications to valproate usage include hepatic dysfunction, mitochondrial disorders, hypersensitivity, urea cycle disorders, and pregnancy.

3.Calcium Channel Blockers

Flunarizine is the best studied of the calcium channel blockers for migraine prevention (however not available in the U.S.). Verapamil and cinnarizine are other meds that are off-label for migraine prevention. Verapamil is probably the most commonly used calcium channel blocker for migraine prevention in the U.S.

Administration

Flunarizine: PO formulation of 5 to 10 mg/day

Verapamil: PO formulation of 120 to 480 mg/day in 3 divided doses

Mechanism of Action

Similar to the other migraine preventive treatments, the role of calcium channel blockers in migraine prevention is unclear. Flunarizine is a nonselective calcium antagonist. In addition to calcium channel activity, it blocks voltage-gated sodium channels, acts as a D2 dopamine antagonist, and increases leptin levels.

Adverse Effects

Adverse effects include constipation, cardiac conduction defects at higher doses, dizziness, constipation, headache, nausea/vomiting, flushing, edema, drowsiness, and hypotension. Lesser common adverse effects include sexual dysfunction, gingival overgrowth, and liver dysfunction.

Contraindications

Contraindications include hypersensitivity reactions, acute coronary syndrome, hypertrophic obstructive cardiomyopathy, severe stenotic heart valve defects, and cardiac conduction disorders.

4.Antidepressants

The most studied antidepressants that have shown efficacy for migraine prevention are the tricyclic antidepressant (TCA) amitriptyline and the selective serotonin reuptake inhibitor (SSRI) fluoxetine. Other TCAs and the serotonin-norepinephrine reuptake inhibitor venlafaxine have been studied and may be effective for migraine prevention, though the evidence is short.

Administration

Amitriptyline: PO formulation of 10 to 150 mg/day

Fluoxetine: PO formulation of 20 to 40 mg/day

Mechanism of Action

Similar to other migraine prevention medications, the role of antidepressants in migraine prevention is unclear. Amitriptyline is a mixed serotonin-norepinephrine reuptake inhibitor and has the following mechanisms: alpha2-adrenoceptor agonist, sodium channel blockade contributing to antimuscarinic and antihistamine effects, and cortical spreading depression.

Fluoxetine is a selective serotonin reuptake inhibitor leading to increased levels of serotonin. Noradrenaline reuptake inhibition occurs at higher doses.

Adverse Effects

Adverse effects of tricyclic antidepressants include antimuscarinic effects such as dry mouth, blurry vision, constipation, urinary retention, increased body temperature, and excessive sweating. Other side effects include morning sedation, tachycardia, vivid dreams, weight gain, hypotension, sexual dysfunction, confusion, and QT prolongation.

Adverse effects of selective serotonin reuptake inhibitors include sexual dysfunction, drowsiness, weight gain, insomnia, dizziness, headache, dry mouth, blurry vision, nausea, rash, tremors, and constipation. SSRIs can also prolong the QT interval.

Contraindications

For TCAs, coadministration with monoamine oxidase inhibitors (MAOI) is contraindicated due to the increased risk of serotonin syndrome. Hypersensitivity reactions and coadministration of cisapride are also contraindicated.

For SSRIs, coadministration of medications that significantly increase the risk of serotonin syndrome is contraindicated. These medications include monoamine oxidase inhibitors, linezolid, and methylene blue. Other contraindications include hypersensitivity reactions and coadministration with pimozide or thioridazine.

3) Other and Future Considerations

1.Triptans with NSAIDs

Research has shown the combined use of a triptan and an NSAID to be more effective than using either drug class alone for acute migraine treatment. The best-studied combination is sumatriptan plus naproxen PO. The two classes of drugs having different mechanisms of action are thought to provide better relief. Multiple studies have used sumatriptan 85 mg plus naproxen 500 mg and sumatriptan 50 mg plus naproxen 500 mg. In a meta-analysis review article, no significant difference was found between using the sumatriptan 85 mg – naproxen combo and the sumatriptan 50 mg – naproxen combo.

2.Lasmiditan

Lasmiditan is a serotonin 5-HT1F receptor agonist that has been shown effective for acute migraine treatment. The utility of this medication is that it lacks vasoconstrictor effects such as those seen in triptans, and thus offers those with cardiovascular disease an alternative to triptans. Studies have used up to lasmiditan 200 mg PO with good effect; however, there were frequent reports of adverse effects. In a recent phase, three multicenter, double-blind, randomized controlled studies, between 25.4% to 39.0% of patients receiving lasmiditan reported adverse effects. The most common adverse effects were dizziness, somnolence, and paresthesias.

3.Calcitonin Gene-Related Peptide (CGRP)

CGRP monoclonal antibodies (mAbs) are the only class of currently used preventives explicitly developed for the treatment of migraines. The current thinking is that CGRP mediates the vasodilatory component of neurogenic inflammation, as CGRP is a widely distributed vasodilator. The CGRP mAbs target either the CGRP molecule itself or the CGRP receptor. In network meta-analysis, the CGRP mAbs seemed to be as effective as other preventive treatments, but have fewer side effects. Long-term data on safety, however, is limited. These medications include erenumab, fremanezumab, and galcanezumab.

Complementary and alternative treatments

Some people get relief with therapies they use in addition to or instead of traditional medical treatment. These are called complementary or alternative treatments. For migraine, they include:

Biofeedback. This helps you take note of stressful situations that could trigger symptoms. If the headache begins slowly, biofeedback can stop the attack before it becomes full-blown.
Cognitive behavioral therapy (CBT). A specialist can teach you how actions and thoughts affect how you sense pain.
Supplements. Research has found that some vitamins, minerals, and herbs can prevent or treat migraines. These include riboflavin, coenzyme Q10, and melatonin. Butterbur may head off migraines, but it can also affect your liver enzymes.
Body work. Physical treatments like chiropractic, massage, acupressure, acupuncture, and craniosacral therapy might ease headache symptoms.

Talk to your doctor before trying any complementary or alternative treatments.

How are migraines treated?

Migraine headaches are chronic. They can’t be cured, but they can be managed and possibly improved. There are two main treatment approaches that use medications: abortive and preventive.

Abortive medications are most effective when you use them at the first sign of a migraine. Take them while the pain is mild. By possibly stopping the headache process, abortive medications help stop or decrease your migraine symptoms, including pain, nausea, light sensitivity, etc. Some abortive medications work by constricting your blood vessels, bringing them back to normal and relieving the throbbing pain.
Preventive (prophylactic) medications may be prescribed when your headaches are severe, occur more than four times a month and are significantly interfering with your normal activities. Preventive medications reduce the frequency and severity of the headaches. Medications are generally taken on a regular, daily basis to help prevent migraines.

What medications are used to relieve migraine pain?

Over-the-counter medications are effective for some people with mild to moderate migraines. The main ingredients in pain relieving medications are ibuprofen, aspirin, acetaminophen, naproxen and caffeine.

Three over-the-counter products approved by the Food and Drug Administration for migraine headaches are:

Excedrin® Migraine.
Advil® Migraine.
Motrin® Migraine Pain.

Be cautious when taking over-the-counter pain relieving medications. Sometimes overusing them can cause analgesic-rebound headaches or a dependency problem. If you’re taking any over-the-counter pain medications more than two to three times a week, report that to your healthcare provider. They may suggest prescription medications that may be more effective.

Prescription drugs for migraine headaches include:

Triptan class of drugs (these are abortives):

Sumatriptan.
Zolmitriptan.
Naratriptan.

Calcium channel blockers:

Verapamil.

Calcitonin gene-related (CGRP) monoclonal antibodies:

Erenumab.
Fremanezumab.
Galcanezumab.
Eptinezumab.

Beta blockers:

Atenolol.
Propranolol.
Nadolol.

Antidepressants:

Amitriptyline.
Nortriptyline.
Zanaflex
Doxepin.
Venlafaxine.
Duloxetine.
Flexeril
Robaxin

Antiseizure drugs:

Valproic acid.
Topiramate.
Gabapentin (Neurontin )

Other:

Steroids.
Phenothiazines.
Corticosteroids.

Your healthcare provider might recommend vitamins, minerals, or herbs, including:

Riboflavin (vitamin B2).
Magnesium.
Feverfew.
Butterbur.
Co-enzyme Q10.

Drugs to relieve migraine pain come in a variety of formulations including pills, tablets, injections, suppositories and nasal sprays. You and your healthcare provider will discuss the specific medication, combination of medications and formulations to best meet your unique headache pain.

Drugs to relieve nausea are also prescribed, if needed.

All medications should be used under the direction of a headache specialist or healthcare provider familiar with migraine therapy. As with any medication, it’s important to carefully follow the label instructions and your healthcare provider’s advice.

Alternative migraine management methods, also known as home remedies, include:

Resting in a dark, quiet, cool room.
Applying a cold compress or washcloth to your forehead or behind your neck. (Some people prefer heat.)
Massaging your scalp.
Yoga.
Applying pressure to your temples in a circular motion.
Keeping yourself in a calm state. Meditating.
Biofeedback.

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What is Muscle Relaxant and Where can I buy Muscle Relaxant online ?

Muscle relaxant is a term usually used to refer to skeletal muscle relaxants (drugs), which act on the central nervous system (CNS) to relax muscles.

: Cyclobenzaprine ( Generic Flexeril )

Muscle relaxants are medications that help reduce muscle spasms, which are involuntary muscle contractions caused by a spine-related problem, such as whiplash, fibromyalgia, or low back strain. Often, muscle spasms cause severe pain and may limit your mobility.

Your doctor may prescribe a muscle relaxant to ease muscle spasms, reduce pain, and help your muscles move better. When your muscles move better, it makes other spine pain treatments, such as physical therapy, stretching, and exercise, more effective.

These drugs are often prescribed to reduce pain and soreness associated with sprains, strains, or other types of muscle injury.

Some examples of commonly prescribed skeletal muscle relaxant medications include carisoprodol (Soma), cyclobenzaprine (Flexeril), and metaxalone (Skelaxin), which are taken in tablet form. Muscle relaxant drugs are only available by prescription in the U.S.

Other types of muscle relaxant drugs (neuromuscular blocking drugs) are sometimes used during the induction of general anesthesia or during insertion of an endotracheal (ET) tube.

These muscle relaxants are given intravenously (through the bloodstream) and act directly on the muscles. Examples of muscle relaxants used during surgical procedures include succinylcholine (Anectine, Sucostrin), atracurium (Tracrium), and pancuronium (Pavulon).

Muscle Relaxants for Muscle Spasms

Muscle spasms are painful and may restrict mobility, which can limit your ability to perform even basic activities. Painful, tight muscles can also interfere with getting a good night’s sleep.

Muscle relaxants may help reduce pain, and improve movement and range of motion, but your doctor will likely recommend that you first try acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). In some cases, these over-the-counter medications will be enough to help alleviate your pain.

If your muscle pain persists, your doctor may prescribe a muscle relaxant in addition to your pain medication. Below are common muscle relaxants (the generic names are listed first, with a brand name example in parentheses):

- Baclofen (Lioresal)
- Carisoprodol (Soma)
- Cyclobenzaprine (Amrix)
- Metaxalone (Skelaxin)
- Methocarbamol (Robaxin)

How Muscle Relaxant Works ?

Muscle relaxation and paralysis can theoretically occur by interrupting function at several sites, including the central nervous system, myelinated somatic nerves, unmyelinated motor nerve terminals, nicotinic acetylcholine receptors, the motor end plate, and the muscle membrane or contractile apparatus.

Most neuromuscular blockers function by blocking transmission at the end plate of the neuromuscular junction. Normally, a nerve impulse arrives at the motor nerve terminal, initiating an influx of calcium ions, which causes the exocytosis of synaptic vesicles containing acetylcholine. Acetylcholine then diffuses across the synaptic cleft. It may be hydrolysed by acetylcholine esterase (AchE) or bind to the nicotinic receptors located on the motor end plate.

The binding of two acetylcholine molecules results in a conformational change in the receptor that opens the sodium-potassium channel of the nicotinic receptor. This allows Na+and Ca2+ ions to enter the cell and K+

ions to leave the cell, causing a depolarization of the end plate, resulting in muscle contraction. Following depolarization, the acetylcholine molecules are then removed from the end plate region and enzymatically hydrolysed by acetylcholinesterase.

Normal end plate function can be blocked by two mechanisms. Nondepolarizing agents, such as tubocurarine, block the agonist, acetylcholine, from binding to nicotinic receptors and activating them, thereby preventing depolarization. Alternatively, depolarizing agents, such as succinylcholine, are nicotinic receptor agonists which mimic Ach, block muscle contraction by depolarizing to such an extent that it desensitizes the receptor and it can no longer initiate an action potential and cause muscle contraction.

Both of these classes of neuromuscular blocking drugs are structurally similar to acetylcholine, the endogenous ligand, in many cases containing two acetylcholine molecules linked end-to-end by a rigid carbon ring system, as in pancuronium (a nondepolarizing agent).

Warnings for Prescription Muscle Relaxants

Muscle relaxants such as carisoprodol and diazepam can be habit forming. Be sure to take your medication exactly as prescribed by your doctor.

Muscle relaxants can also cause withdrawal symptoms, such as seizures or hallucinations (sensing things that aren’t real). Do not suddenly stop taking your medication, especially if you’ve been taking it for a long time.

Also, muscle relaxants depress your central nervous system (CNS), making it hard to pay attention or stay awake. While taking a muscle relaxant, avoid activities that require mental alertness or coordination, such as driving or using heavy machinery.

You should not take muscle relaxants with:

- - alcohol
  - CNS depressant drugs, such as opioids or psychotropics
  - sleeping medications
  - herbal supplements such as St. John’s wort

Talk to your doctor about how you can safely use muscle relaxants if you:

are older than 65 years
have a mental health problem or brain disorder
have liver problems

List of Common Muscle Relaxers

Muscle relaxers are usually prescribed to treat back pain in conjunction with rest and physical therapy. Common muscle relaxants include:

Baclofen. Muscle tightness and muscle spasms, including those related to spine injuries, may be eased with baclofen. The medication may be helpful in treating multiple sclerosis and stabbing nerve pain. It is available as a tablet and can be taken by children as young as 12 years old. Some common side effects could include nausea and vomiting, confusion, drowsiness, headache, or muscle weakness. Baclofen is rated C in the FDA’s A through X pregnancy safety ranking for medications, with A being the safest. The C category means that the medication should only be used if the benefits outweigh the risks.
Benzodiazepines. In addition to treating anxiety, alcohol withdrawal, and seizure disorders, such as epilepsy, benzodiazepines can also treat muscle spasms and skeletal pain. Benzodiazepines, such as diazepam (Valium), lorazepam (Ativan), and temazepam (Restoril), are typically only intended for short-term use. This limitation is due to their habit-forming potential and because they alter sleep cycles, leading to sleep difficulties once the drug is stopped. Benzodiazepines are sold as tablets, liquid, injections, and rectal gels. People who have myasthenia gravis, severe liver disease, serious breathing troubles, or some forms of glaucoma, should avoid taking diazepam. All benzodiazepines are rated D by the FDA for safety during pregnancy and are not recommended for women who are pregnant.
Carisoprodol (Soma). Carisoprodol relaxes muscles and eases pain and stiffness caused by acute bone and muscle problems, often caused by an injury. It is taken by mouth in tablet form and is also available in combination with aspirin or aspirin and codeine. Carisoprodol can be habit-forming, particularly if used in conjunction with alcohol or other drugs that have a sedative effect, including opioids (such as codeine). Common side effects include drowsiness, dizziness, and headache. People with a history of blood disorders, kidney or liver disease, and seizures may need to avoid Carisoprodol. It is rated C in the FDA’s pregnancy safety ranking for medications.
Chlorzoxazone (Lorzone). Chlorzoxazone is used for the relief of discomfort from acute, painful, musculoskeletal conditions. Chlorzoxazone is available as a tablet. Common side effects include drowsiness, dizziness, and nausea. Chlorzoxazone is not recommended for people with liver disease. It has not been rated by the FDA for safety during pregnancy.
Cyclobenzaprine (Amrix, Fexmid, FlexePax Kit, FusePaq Tabradol). Cyclobenzaprine eases stiffness and pain from muscle cramps, also called muscle spasms. It is available as a tablet and extended-release capsule. Cyclobenzaprine itself is not intended for long-term use (more than 2 to 3 weeks). Common side effects include blurred vision, dizziness or drowsiness, and dry mouth. It is not advised for those with an overactive thyroid, heart problems, or liver disease. Cyclobenzaprine is rated B by the FDA for safety during pregnancy, making it the safest muscle relaxant to use while pregnant.
Dantrolene (Dantrium). Dantrolene helps control chronic spasticity related to spinal injuries. It is also used for conditions such as stroke, multiple sclerosis, and cerebral palsy. Dantrolene is taken as a capsule or intravenous powder for injection. Drowsiness and sensitivity to light are common side effects. It can cause severe liver problems, and should not be taken by people with active liver disease. The FDA has given dantrolene a C rating for safety in pregnancy.
Metaxalone (Skelaxin, Metaxall, and Metaxall CP, Lorvatus PharmaPak). Metaxalone targets pain and muscle spasms from sprains, strains, and muscle injuries. It is available as a tablet or injection. Common side effects include drowsiness, dizziness, nausea, and vomiting. Metaxalone is generally not recommended for people with a known tendency to become anemic, and who have kidney or liver disease. Metaxalone may affect blood sugar tests for people with diabetes. The FDA has not rated metaxalone for safety during pregnancy.See Pulled Back Muscle and Lower Back Strain and Neck Strains and Sprains Video
Methocarbamol (Robaxin, Robaxin-750). Methocarbamol eases acute muscle and bone pain. It can be taken as a tablet or by injection. Common side effects include dizziness, headache, nausea, flushing, and blurred vision. Methocarbamol is generally not recommended to people with renal disease or failure, or a history of allergic reaction to the medication. The FDA has given methocarbamol a C rating for safety during pregnancy.
Orphenadrine. Orphenadrine is a medication used to relieve pain and stiffness caused by muscle injuries. It is available as an extended-release tablet. Common side effects include dry mouth, lightheadedness, difficult urination, heartburn, nausea and vomiting. It is generally not recommended to people with previous sensitivities to the ingredients, myasthenia gravis, those with glaucoma or certain types of ulcers. The FDA has given orphenadrine a C rating for safety during pregnancy.
Tizanidine (Comfort Pac with Tizanidine, Zanaflex). Tizanidine is used to treat muscle spasms caused by spinal cord injuries and other conditions such as multiple sclerosis. Tizanidine is available in tablet and capsule form and absorbs differently depending on whether it is taken on an empty stomach or with food. Common side effects include dry mouth, dizziness, constipation and tiredness. It should not be used by people taking fluvoxamine or ciprofloxacin or those who have liver disease. Tizanidine is rated in the C category for safety during pregnancy.
Buspirone (BuSpar, BuSpar Dividose, Vanspar) -Buspirone is an anti-anxiety medicine that affects chemicals in the brain that may be unbalanced in people with anxiety. Buspirone is used to treat symptoms of anxiety, such as fear, tension, irritability, dizziness, pounding heartbeat, and other physical symptoms. Buspirone is not an anti-psychotic medication and should not be used in place of medication prescribed by your doctor for psychotic disorders.

What is the best over-the-counter (OTC) medicine for muscle pain?

These are the medications that you can find while perusing the aisles at your local pharmacy or convenience store. Most of them are household names, and it’s not uncommon to keep them on hand, stashed in a medicine cabinet, just in case. Even though OTC medications are easy to obtain, they’ll do the job for many aches and pains, and doctors often recommend them prior to prescribing stronger treatment options.

“OTC NSAIDS, like ibuprofen and naproxen, are a good first line agent to decrease inflammation surrounding an injury,” recommends Joanna Lewis, Pharm.D., creator of The Pharmacist’s Guide. They might not have the same potency of high-grade muscle relaxants, but they’re still effective and have very few side effects. If you roll your ankle at the gym or wake up with back pain, try one of these before asking your doctor for a prescription.

Advil (ibuprofen): This is a staple of parents, doctors, and athletes alike. Ibuprofen is one of the most widely used nonsteroidal anti-inflammatory drugs (NSAIDs) available. As such, Advil doesn’t just remedy pain, but also inflammation as well. It’s highly versatile. Use it to treat low back pain, osteoarthritis, menstrual cramps, fever, headaches, migraines, sprains, and other minor injuries. Low doses are available over the counter, but a doctor can prescribe higher doses as well.
Motrin IB (ibuprofen): Don’t be fooled by the different brand name. Motrin IB and Advil are the same drug. Therefore, they shouldn’t be taken together, as it could increase the risk of overdose.
Aleve (naproxen): Another medicine cabinet staple, naproxen is similar to ibuprofen in many ways. It’s also an NSAID, so it works by reducing inflammation. It’s useful in treating muscle pain, headaches, migraines, osteoarthritis, fever, cramps, and minor injuries. The main difference between naproxen and ibuprofen is their dosing. You can take naproxen every eight to 12 hours and ibuprofen every four to six, so Aleve is slightly longer-lasting.
Aspirin: One more NSAID for you. Aspirin treats many of the same conditions, relieving pain and reducing inflammation. However, daily doses of aspirin have been proven effective at reducing the risk of blood clots, strokes, and heart attacks in some people. Ask your doctor before using for clot prevention. If you’re a candidate, you will likely take a “baby” aspirin, or 81 mg, coated tablet daily. Common brand names include Bayer or Ecotrin.
Tylenol (acetaminophen): Unlike NSAIDs, acetaminophen focuses solely on treating pain—not inflammation. It’s used for muscle aches, headaches, migraines, back and neck pain, fevers, etc. However, if swelling and inflammation is the underlying cause of your pain, acetaminophen will not be nearly as effective as NSAIDs like those listed above. Acetaminophen’s wide range of uses and relatively few side effects make it the most popular OTC pain reliever worldwide.

Off-label medications for spasticity

Doctors can use certain medications to treat spasticity even when the drugs are not approved for that purpose by the U.S. Food and Drug Association (FDA). This is called off-label drug use. The following drugs are not actually muscle relaxants, but they can still help relieve symptoms of spasticity.

Benzodiazepines

Benzodiazepines are sedatives that can help relax muscles. They work by increasing the effects of certain neurotransmitters, which are chemicals that relay messages between your brain cells.

Examples of benzodiazepines include:

- - clonazepam (Klonopin)
  - lorazepam (Ativan)
  - alprazolam (Xanax)

Side effects of benzodiazepines can include drowsiness and problems with balance and memory. These drugs can also be habit forming.

Clonidine

Clonidine (Kapvay) is thought to work by preventing your nerves from sending pain signals to your brain or by causing a sedative effect.

Clonidine should not be used with other muscle relaxants. Taking it with similar drugs increases your risk of side effects. For instance, taking clonidine with tizanidine can cause very low blood pressure.

Clonidine is available in brand-name and generic versions.

Gabapentin

Gabapentin (Neurontin) is an anticonvulsant drug typically used to relieve seizures. It’s not fully known how gabapentin works to relieve muscle spasticity. Gabapentin is available in brand-name and generic versions.

what is muscle relaxant Side Effects?

Some of the common side effects of muscle relaxers include:

Drowsiness
Dizziness
Agitation
Irritability
Headache
Nervousness
Dry mouth
Decreased blood pressure
Sleepiness or grogginess
Fatigue
Dry mouth
Constipation
Nausea

More serious side effects include:

Light-headedness or fainting
Blurred vision
Confusion
Urinary retention

Any serious side effects should be reported to a doctor immediately.

Risks Associated with Muscle Relaxers

Muscle relaxers are a group of drugs that have a sedative effect on the body. They work through the brain, rather than directly on the muscles. Muscle relaxants are generally used for a few days and up to 3 weeks, but are sometimes prescribed for chronic back pain or neck pain.

To minimize risk, the doctor should be informed of any history of seizures, liver disease, and any other medical conditions or concerns. Women should inform their doctors if they are pregnant, plan to become pregnant, or are breast-feeding.

Sleepiness. Because muscle relaxers are total body relaxants, they typically induce grogginess or sleepiness. As a result, it is not safe to drive or make important decisions while taking muscle relaxers. Muscle relaxers are often suggested for evening use due to their sedative effect.
Interactions with alcohol. Drinking alcohol can be especially dangerous when taking muscle relaxers. The sedative effect of the medication is intensified with alcohol use, and combining the two can be fatal.
Allergic reactions. No medication should be taken if the person has had an allergic reaction to it in the past, even if the reaction seemed mild. Symptoms of an allergic reaction include swelling in the throat or extremities, trouble breathing, hives, and chest tightness.
Potential for abuse. Muscle relaxers have a risk of misuse and abuse. Some muscle relaxers, such as cyclobenzaprine, can be habit-forming on their own. Others may be taken in conjunction with other drugs, such as opioids, to create a high, and are therefore more likely to be abused.
Tapering off. Stopping a muscle relaxer abruptly can be harmful. Instead, the doctor will prescribe a gradual reduction in dosage.

Muscle Relaxer Abuse

Muscle relaxers have a potential for abuse and addiction. Prolonged use can lead to increased tolerance and physical dependence, especially with Soma. For this reason, muscle relaxers are intended as a short-term treatment not to be prescribed for more than 2-3 weeks.

Unfortunately, many individuals take muscle relaxers alone or in combination with other illicit drugs for nonmedical reasons, such as to produce or enhance feelings of euphoria and dissociation. According to the Drug Enforcement Administration, Soma is one of the most commonly diverted drugs in the United States.

Evidence also indicates prevalent misuse of Flexeril. In 2010 there were over 12,000 emergency room visits associated with Flexeril, and in 2016 over 10,000 calls to the Poison Control Centers had involved Flexeril.1

Muscle relaxer abuse can lead to serious dangers such as an increased risk of overdose, which can result in:

- - stupor
  - hallucinations
  - seizures
  - shock
  - respiratory depression
  - cardiac arrest
  - coma
  - death

Alcohol and Muscle Relaxers

Like muscle relaxers, alcohol also depresses the central nervous system. When alcohol is consumed with muscle relaxers the side effects are exacerbated. This can be very dangerous, leading to symptoms like:

- - Blurred vision
  - Urine retention
  - Extreme dizziness
  - Extreme drowsiness
  - Low blood pressure
  - Fainting
  - Memory problems
  - Liver damage
  - Increased risk of overdose

It is recommended to not drive or operate heavy machinery when under the influence of muscle relaxers. It is especially important to avoid drinking, as combining muscle relaxers with alcohol greatly increases your risk of an accident.

Withdrawal and Treatment

Regular use of muscle relaxers causes the brain to become used to its effects. If you attempt to suddenly stop using muscle relaxers you may experience withdrawal symptoms. Depending on the specific drug and how long you have been using it, there are various treatment options available to help you overcome your addiction.

For many people, Flexeril withdrawal causes mild symptoms such as nausea, headache, drowsiness, malaise, and discomfort. Symptoms tend to peak about 2-4 days after you last took the Flexeril, although in some people withdrawal symptoms may last for up to 1-2 weeks. For many people Flexeril detox can be done at home. However, if Flexeril addiction is accompanied by alcohol or opioid abuse the withdrawal symptoms from these other substances can be severe. In these situations, it may be best to undergo professional medical detox.

Soma withdrawal is usually more severe and can include symptoms like hallucinations and seizures. For your safety and comfort, it is often best to find an inpatient treatment program that includes a detox program to manage withdrawal symptoms. After detox patients can transition into the actual treatment phase of the program. Some people may not require a supervised detox program and will be able to undergo treatment on an outpatient basis.

Most inpatient and outpatient rehab programs include cognitive behavioral therapy that will help you learn the coping skills needed for long-term recovery.