Still getting migraines despite medication? What to do when headaches won’t go away despite treatment

Migraines are common, but for some people, they can become a relentless illness, with headaches occurring several times a week, interfering with work, sleep, family life and overall quality of life. The good news is that we now have more effective treatments for migraines than ever before.

But when a person continues to have frequent or severe headaches despite treatment, simply adding another medicine is not always the answer. The first step is to ask: “Are we treating the right problem?”

Reconfirm the diagnosis

Migraine is diagnosed primarily from the patient's history. There is no blood test or brain scan that can confirm it. A person with frequent headaches should therefore have the diagnosis reviewed carefully. Migraine can coexist with other headache disorders, and some secondary conditions can mimic or worsen migraine.

Attention should be paid to warning signs such as a sudden 'worst-ever' headache, a new headache after age 50, progressive worsening, fever, seizures, new neurological symptoms, visual abnormalities or a headache associated with cancer, immune suppression or pregnancy. These situations may require further investigation.

Conditions such as raised intracranial pressure, including idiopathic intracranial hypertension (IIH), medication-overuse headache, sleep disorders and other neurological disorders should be considered when the clinical picture is atypical.

Importantly, not every person with frequent headache needs an MRI. For someone with a typical migraine history and a normal neurological examination, routine brain imaging is generally unnecessary.

Look for medication overuse

This is one of the most missed reasons why migraine becomes difficult to control. People understandably take painkillers or migraine-specific medicines more frequently when headaches become frequent. Unfortunately, repeated use of acute headache medication can itself contribute to medication-overuse headache, creating a vicious cycle of headache → medication → temporary relief → more headaches.

Medication-overuse headache should be suspected when headache occurs on at least 15 days a month in someone with a pre-existing headache disorder and acute medications are being regularly overused for more than three months. The threshold is generally 10 days per month for triptans, opioids or combination analgesics and 15 days per month for simple analgesics such as paracetamol or NSAIDs.

Recognising and treating this problem can sometimes dramatically improve migraine without adding another preventive drug.

Look beyond the headache

Migraines do not occur in isolation. Depression, anxiety, poor sleep, chronic stress and other medical conditions are more common among people with migraines and can make the illness harder to control. These conditions should be actively identified and treated rather than dismissed as being 'just psychological'.

Sleep deprivation, irregular sleep schedules, skipped meals, dehydration and excessive caffeine can also worsen migraines in susceptible individuals.

A headache diary can be extremely useful. It records headache days, severity, duration, associated symptoms, menstrual relationship, acute medications and possible triggers. It can help distinguish genuine patterns from suspected triggers.

Patients should also avoid unnecessarily eliminating food options. Food should generally be avoided only when a relationship with migraine has been established.

Check whether preventive treatment has been adequate

Sometimes a treatment is labelled a 'failure' when it was taken at too low a dose, for too short a period, or inconsistently because of side effects. The choice of preventive treatment should be individualised according to the person's other medical conditions, age, pregnancy considerations, lifestyle and preferences.

And failure of one preventive drug does not mean that treatment will fail altogether. There are multiple classes of preventive treatments.

Migraine-specific treatments

This is where the treatment landscape has changed dramatically.

CGRP-targeting therapies, including monoclonal antibodies such as erenumab as well as oral CGRP-targeting medicines called gepants, are specifically designed to prevent migraines.

The American Headache Society now considers CGRP-targeting therapies a first-line option for migraine prevention, without requiring patients to fail several older preventive medicines first. They have demonstrated efficacy in both episodic and chronic migraine and are generally well tolerated.

For people with chronic migraine (headache on at least 15 days a month for more than three months, with migraine features on at least eight days), botox is another established preventive treatment. In clinical trials, it significantly reduced headache days and improved quality of life.

Other options, including non-invasive neuromodulation devices, can be considered in selected patients. These use electrical or magnetic stimulation of specific nerves or brain regions to influence migraine pathways.

'Difficult-to-treat migraine' should not mean 'nothing more can be done'. Before moving to newer and more expensive treatments, reassess the diagnosis, look for medication overuse and secondary causes, address sleep and psychological comorbidities, identify modifiable factors and ensure that preventive treatment has been used appropriately.

If migraine remains frequent and disabling despite these measures, modern migraine-specific therapies have opened an entirely new chapter in treatment.

The opinions expressed in this article are those of the author and do not purport to reflect the opinions or views of THE WEEK.