* Botox. Injections of the solution -- a form of botulism -- blocks nerve signals that cause muscles to contract. With migraines, injections are usually made across the forehead, in the temples and in the back of the neck.
* Surgery. Nerve decompression surgery tries to loosen up anything that might be impinging or squeezing nerves, be it muscle, bone or something else, but studies from the American Headcahe Society call it "a last-resort option."
* Implanted neurostimulation. These devices use wires to deliver electric zaps to nerves that might be causing migraines, blocking the pain. The stimulators are planted udner the skin in near the forehead or the back of the neck while the battery is set in the chest wall or above the buttocks. Patients can control the strength of the electric current.
• Over-the-counter medications such as aspirin, acetaminophen or ibuprofen.
• Prescription only indomethacin is available as a suppository, which helps if nausea accompaniues the migraine.
• Triptans constrict blood vessels and block pain pathways in the brain. They include sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), naratriptan (Amerge), zolmitriptan (Zomig), frovatriptan (Frova) and eletriptan (Relpax). Triptans are available as pills, nasal sprays and injections.
• Ergots seem most effective for pain lastinglasts for more than 48 hours.
• Anti-nausea medications such as chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro) are sometimes necessary because of migraine-produced nausea.
• Opioid medications containing narcotics, especially codeine, are used by those who can't take triptans or ergot.
• Glucocorticoids such as prednisone or dexamethasone may be used with other medications to improve pain relief.
• Cardiovascular beta blockers such as propranolol (Inderal La, Innopran XL, others), metoprolol tartrate (Lopressor) and timolol (Betimol) may reduce the frequency and severity of migraines.
• Antidepressants. Amitriptyline has proven effective in preventing migraines.
• Anti-seizure drugs such as valproate sodium (Depacon) and topiramate (Topamax), seem to reduce the frequency of migraine headaches.
• Massage therapy
• Cognitive behavioral therapy
• Herbs, vitamins and minerals
When the migraines come on - and they come on sometimes as often as two or three times a week - Nancy Collum has "an arsenal of things to make them go away."
From nasal sprays to pills to narcotics to injections, she's tried them all.
"Nothing works every time," she says.
While most everyone suffers from the occasional headache, some quite painful, migraines are the locomotives of the headache world, roaring into a person's head and taking over their entire body.
Symptoms can include not only ferocious pain, but swollen eyes, nausea, aversion to light or sound, and pressure inside the skull that's so intense, it feels as if your eyes might pop out at any second. According to Mayoclinic.com, they can last for hours or days and be "so severe that all you can think about is finding a dark, quiet place to lie down."
Sufferers of migraines -- be they chronic or occasional -- have an arsenal of medications to deal with the pain. There are dozens of drugs that fall into pain-relieving or preventative categories, and there also are newer techniques that include Botox injections, surgery, implanted neurostimulation devices and nerve decompression. Still, such drugs and treatments can relieve the symptoms for some patients for a time, but they don't work on everyone.
And they can be expensive. Botox injections, for example, can cost around $1,000 per treatment, involve as many as 31 injections, and the drug lasts about three months, according to a story in the Dallas Morning News. Even then, Botox is only recommended for sufferers of chronic migraines, which are defined as headaches at least 15 days a month, with eight of those being severe.
Dr. Sharon Farber at Chattanooga Neurology says she wants to see more research results before she would recommend some of the newer, more drastic treatments such as surgery or Botox for her patients. WIth surgery, the general feeling is that about 50 percent of patients get better, she says, but she thinks the actual figure is lower.
"And it's very expensive and uncomfortable. And you always worry when you do surgery."
She is also careful about prescribing medications and cautions people about using meds that are high in caffeine because they can cause rebound or transformed migraines.
"Basically, you get dependent on them," she says. "[Patients] take a pill for the migraine, they have a headache from the caffeine withdrawal and take another pill and get a migraine. It's incredibly common. I've seen entire families who've been doing it for 40, 50 years."
Farber prefers her patients to be on as few medications as possible, and she rarely prescribes narcotics.
"Bcause then they just end up with a monkey on their backs as well as having headaches."
Migraines appear to be genetic, which causes Farber to be pessimistic about ever completely ridding people of them, and while there are a number of treatment options, there is no one-size-fits-all.
"We tend to look at them based on the individual. We look at the whole person."
For Collum, the migraines usually come at night, and she has learned over the years that the best remedy is to put one ice pack on her forehead, one on her neck, then crawl back into bed in a dark, cold room to wait it out. The waiting can take a few hours or several, which means that any plans she may have had are put on hold, and that includes work, dinner with a friend or a family birthday party.
"The worst part is I can not follow through with commitments I've made with family, friends and co-workers," she says.
Fortunately, her job at First Volunteer Bank is more clerical and doesn't involve dealing with the public. She says management allows her to work a schedule that fits her needs.
"I have been very fortunate to have supervisors who were understanding and believed in my character, but I do have to think in the back their minds they are thinking, 'She's just tired and laying out.' But, I have been fortunate."
Counseling helped her understand how to explain to co-workers what she is going through.
"I always worried I would sound like a whiny brat, but I learned how to say, 'Hey, I'm having a migraine. We can continue to talk or we can reschedule this for tomorrow.'"
Collum says her propensity for migraines appears to be hereditary since her grandmother and mother had them. As a child, she got them a couple times a year, and they've increased dramatically in frequency in her adult life.
"Recently I've had three or four a week for months, but [two weeks ago] was a great week. I didn't have a single headache."
But then Tuesday rolled around and she had one that "felt like a piece of steel rebar was pounded into my head and it came out of my neck."
As you might guess, Collum has tried numerous remedies and been to a number of doctors. She has stuck to fairly traditional methods, she says. She hasn't tried acupuncture or a chiropractor, for example, for a couple of reasons. First, she says, even the friends who have tried them or the others say it helps, but it's not a cure, and she doesn't like the idea of not being able to immediately get help when a migraine comes on.
The most unusual remedy she tried, based on the recommedation of a friend, was filling the bathtub with hot water and soaking her elbows in the water.
"Water slopped everywhere and I still had a headache," she says.
Contact staff writer Barry Courter at firstname.lastname@example.org or 423-757-6354.