When Migraines Worsen, Consider Injection or Bridge Therapies

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May 26, 2022
May 25, 2021
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When Migraines Worsen, Consider Injection or Bridge Therapies

Why does migraine worsen?

Episodes of migraine can become more frequent, and chronic migraine can become worse - sometimes for obvious reasons, and sometimes without any cause.  Any time your headaches get worse it’s important to discuss this with your doctor, since he or she may want to run a blood test or consider getting imaging, depending on your symptoms. 

It’s important to use your "as needed" migraine medications, but when migraine worsens they might not work quite as well.  Many "as needed" migraine medicines have a limit on how many times a week you can take them, and we often don’t want to have to add extra medications if we don’t need to.  For this reason, when migraine worsens many doctors prefer giving you a short course of medication to “bridge the gap” between prevention and acute treatment. Here are a few solutions in that area:

Anti-inflammatories

Many longer-lasting anti-inflammatory medications can be helpful in breaking up a bad migraine cycle. Naproxen 500 mg and Nabumetone 500-750 mg twice daily for 5-7 days are the most common choices.  Tell your doctor if you have bad heartburn or gastritis, since you may need to take an antacid medication while using this, or this might not be the best choice for you. 

Steroids

If you’ve been using anti-inflammatories already and your migraine is still getting worse, your doctor might consider a short steroid course.  This usually entails an initial higher dose of steroid with decreasing amounts of pills daily.  Prednisone and dexamethasone are both common steroids, sometimes for convenience you might be prescribed a Medrol dose pack which has the instructions as part of the package.  The most common side effects are stomach upset and insomnia - we recommend taking this in the morning with food. If you have diabetes this may elevate your blood sugar level, and it might not be the best choice for you. 

Anti-Nausea Medications

If nausea is a particularly significant symptom of your worsening migraines, your doctor might consider a course of anti-nausea medications that also help migraine attacks.  Reglan, or metoclopramide is a common choice, and can be given 2-3 times daily for 5-7 days.  

Nerve Blocks 

Another option your doctor might consider is a set of injections in specific areas of the scalp, called nerve blocks.  These are done with a combination of lidocaine-type medications, targeting superficial nerves around the head, such as the greater and less occipital nerves, or small branches of the trigeminal nerve.  This might be particularly helpful if you are experiencing really severe tenderness around the head, especially in the areas of these nerves.  

IV Medications

Your doctor might also recommend a combination of IV medications that can help break a bad migraine cycle.  This might be done in an outpatient infusion center, an urgent care center, an emergency room, or even after being admitted to the hospital.  This will usually be reserved until after you’ve tried at least some of the other options above. Most commonly, you are given an anti-inflammatory and anti-nausea medication, in addition to magnesium.  A number of other medications are available as well, including some anti-seizure medications that can be helpful, and DHE - also known as dihydroergotamine, an older medication that can be very effective for migraine.  Some inpatient headache programs even offer IV lidocaine or ketamine as part of a protocol.  

If you feel like your current symptoms are getting worse or the treatment you are getting doesn't improve your headache, join Neura Health and get the help you need!

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Thomas Berk, MD
Thomas Berk is Medical Director at Neura Health and a Clinical Assistant Professor at the Department of Neurology at NYU Grossman School of Medicine
About the Author
Dr. Thomas Berk is Medical Director of Neura Health and a neurologist and headache specialist based in New York City. He has over 12 years of clinical experience, having graduated from the NYU Grossman School of Medicine in 2010. He completed his neurology residency at NYU as well and is a board-certified headache specialist, having completed a headache fellowship at the Jefferson Headache Center. He is an emerging leader of the American Headache Society and has been on the Super Doctors list of rising stars for the past five years.

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