Migraine Care Has Changed — and Most Patients Haven't Heard
For decades, migraine prevention meant blood pressure pills, antidepressants, or anti-seizure drugs that were never designed for headaches. They helped some patients but caused side effects that drove others to stop. Since 2018, an entirely new drug class — CGRP inhibitors — has redefined what's possible. If you have migraines and have not revisited your treatment in the past few years, you are likely missing options that could change your life.
At Zimmer Medical Group, we routinely start migraine workups in primary care and connect patients to neurology only when truly needed.
Abortive vs. Preventive: Two Different Strategies
Migraine treatment has two completely separate goals:
- Abortive (acute) treatment stops a migraine that has already started. Triptans (sumatriptan, rizatriptan), ditans (lasmiditan), gepants (ubrogepant, rimegepant), and over-the-counter combinations like acetaminophen-aspirin-caffeine fall in this group.
- Preventive treatment is taken regularly to reduce how often migraines occur and how severe they are when they do. CGRP inhibitors, beta blockers, topiramate, amitriptyline, and Botox are preventive.
Most patients with four or more migraine days per month — or fewer days but significant disability — qualify for preventive therapy. Many never get offered it.
What CGRP Inhibitors Actually Do
Calcitonin gene-related peptide (CGRP) is a molecule released during migraine attacks that drives pain and inflammation in blood vessels around the brain. CGRP inhibitors block either the molecule itself or its receptor:
- Monthly or quarterly injections: erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), and eptinezumab (Vyepti, IV every three months)
- Daily oral tablets: atogepant (Qulipta) and rimegepant (Nurtec, which works for both prevention and acute treatment)
These medications cut migraine days roughly in half for most responders. Side effects are notably milder than older preventives — typically injection-site reactions, constipation (with erenumab), or mild upper respiratory symptoms.
The American Headache Society now recommends CGRP inhibitors as first-line preventive options alongside traditional drugs, not as last-resort choices.
When to Treat with Older Preventives First
Insurance often requires a trial of older preventives before approving CGRP inhibitors. The traditional options remain useful and inexpensive:
- Beta blockers (propranolol, metoprolol) — particularly helpful if you also have hypertension
- Topiramate — effective but causes word-finding difficulty and tingling for many patients
- Amitriptyline — helpful when migraines coexist with insomnia or chronic tension headache
- Onabotulinumtoxin A (Botox) — FDA-approved for chronic migraine (15+ headache days per month)
If side effects derail you on these older drugs, your insurance is far more likely to authorize a CGRP inhibitor.
Identifying Migraine Triggers (and Which Ones Actually Matter)
Trigger lists are notoriously long, but the evidence-supported ones are shorter:
- Sleep changes — both too little and too much
- Skipped meals and dehydration
- Hormonal cycles in menstruating women
- Weather and barometric pressure changes — particularly relevant in Florida storms
- Alcohol — especially red wine and aged spirits
- Bright lights, strong odors, and screen overuse
A two-week migraine diary often reveals patterns that years of guessing have missed.
Medication Overuse Headache: The Hidden Problem
Taking acute migraine medication more than 10–15 days per month can paradoxically cause more frequent headaches — a syndrome called medication overuse headache. Patients often increase their abortive use, which worsens the cycle.
Common offenders include over-the-counter combination painkillers (Excedrin), butalbital-containing medications (Fioricet), opioids, and frequent triptan use. Breaking the cycle requires tapering the offending medication while starting a preventive — exactly the situation where CGRP inhibitors shine because they don't require titration.
Red Flags That Need Imaging
Most migraines do not require an MRI. Red flags that change that calculus include:
- A new "thunderclap" headache that peaks within seconds
- Headaches that wake you from sleep
- New headache after age 50
- Headache with fever, neck stiffness, or new neurological symptoms
- Progressive worsening over weeks
- Headache that changes character substantially
Without these features, imaging usually adds anxiety and cost without changing care. The American College of Radiology appropriateness criteria support this conservative approach.
What Primary Care Can Handle
A surprising amount of migraine care belongs in primary care, not neurology:
- Initial diagnosis and ruling out red flags
- Lifestyle and trigger counseling
- Starting and titrating standard preventives
- Prescribing triptans and gepants for acute attacks
- Initiating CGRP inhibitors when older preventives fail or are contraindicated
- Coordinating with mental health support when migraines coexist with anxiety or depression
Neurology referral makes sense for chronic migraine, status migrainosus, atypical features, or treatment-resistant cases.
Starting a CGRP Inhibitor: What the First Three Months Look Like
The most common reason a new migraine preventive gets abandoned is that nobody explained how to judge it.
Give it a fair trial and measure it
Injectable CGRP antibodies such as erenumab, fremanezumab, and galcanezumab are usually judged after about three months, and I ask for a simple headache calendar from day one: migraine days, severity, and the acute medication used. Some people respond within the first month; others improve steadily and only see it clearly when they compare month three to the month before starting. Prior authorization is routine and usually requires that calendar plus the list of preventives already tried, so bring both. NINDS has a readable summary of the drug classes if you want to compare them.
Who needs extra caution
CGRP is involved in widening blood vessels, so we go slowly in people with a history of stroke, heart attack, or uncontrolled blood pressure, and erenumab carries a specific warning about new or worsening hypertension. These drugs are generally avoided during pregnancy and breastfeeding because the data are thin, and constipation with erenumab can be stubborn enough in older adults to matter. None of this means no; it means the decision is made with the whole chart in view. Anyone with an unclear history sees our neurologic team.
Headaches that are not migraine
Before escalating, I re-check the diagnosis. Daily pressure across the forehead and cheeks in a Florida allergy season is often sinusitis or rhinitis rather than migraine, though the two overlap more than people expect. A headache that is present on waking most days and eases through the morning is medication overuse until proven otherwise. And any headache that is new after 50, worse with coughing or straining, or paired with jaw pain, scalp tenderness, and vision changes needs a same-week workup rather than another preventive, as MedlinePlus also emphasizes. Gulf Coast heat adds one more trigger: dehydration after a morning outside is one of the most common causes of an afternoon attack, and our hydration guide is worth a read for anyone whose migraines cluster in summer.
Your Next Step
If you have not had a migraine plan reassessed in three or more years, the landscape has shifted under your feet. Bring a two-week headache log to your next appointment and ask specifically about CGRP options.
Tired of cycling through the same migraine medications? Schedule a visit with Zimmer Medical Group for a fresh look at your headache plan and the modern options that may be a fit.
