It’s all based on patient preference. For example, I saw a patient yesterday who told me off the bat, “I don’t want to take any medications. Can you give me a preventive and a rescue approach that’s not a medication?” I also see some patients who are open to mainstream medications and nonmedication options. So I try to have a nice balance in my practice of both of those things, of nonmedication treatments and medication treatments.
Mainstream treatments have a ton of evidence for the treatment of migraine and are studied vigorously. These include preventive medications for migraine, seizure medications, antidepressant medications, blood pressure medications, and Botox to prevent migraine. For rescue treatment of migraine, we use anti-inflammatory medications called triptans, gepants, and ditans.
Other mainstream treatments include devices like the CEFALY device, which has also been rigorously studied in randomized sham control trials. I always talk about those migraine devices with patients, too, because they do have a good amount of evidence and they’ve been studied in clinical trials.
Some patients want to add integrative medicine approaches to their mainstream treatment. We might discuss vitamins or physical therapy, acupuncture, and psychology approaches, such as cognitive behavioral therapy and biofeedback, because we know that many people who have migraine—almost half of them—also have anxiety.