My sister, 31, has migraines despite injections. How to manage?

Question

Hello doctor,

My 31-year-old sister suffers from chronic migraines and finally got approved for migraine injection treatments, but has been having mixed results. She gets Botox injections every three months for prevention, but still has 15 to 20 migraine days per month.

When she gets a severe attack, she uses Sumatriptan injection, which works but makes her feel like she is having a heart attack with chest tightness and arm pain. Her neurologist also prescribed Aimovig monthly injection, but after four months has not seen much improvement in frequency.

The worst part is that her migraines got much worse after having her baby 18 months ago, and she cannot take most medications while breastfeeding. She tried magnesium supplements and Riboflavin, but they upset her stomach.

Her migraine injection treatments are costly even with insurance, and we cannot afford to keep paying for something that is not working well. She also has to miss work frequently because attacks are so severe that she cannot drive or look at a computer screen.

Can she try a different type of migraine injection, or should she stop breastfeeding to try stronger medications? I am worried because family history shows migraines run in women on my mother's side.Please advise.

Answer 1

Hello,

Welcome to icliniq.com

I understand your concern for your sister. Chronic migraines that persist despite multiple treatments can be exhausting for both patient and family. Botox and Aimovig (Erenumab) are both valid preventive options, but if she is still having 15 to 20 migraine days per month, this qualifies as refractory chronic migraine.

Other CGRP (calcitonin gene-related peptide) monoclonal antibodies (like Ajovy [Fremanezumab] or Emgality [Galcanezumab] sometimes work better if one does not.

The chest tightness with Sumatriptan injection can mimic a heart attack; it is a common side effect called triptan sensations. In such cases, alternatives like Lasmiditan or Gepants (Ubrogepant, Rimegepant) may be safer, but their use in breastfeeding is limited.

Since she is still breastfeeding, medication options are restricted. Stopping breastfeeding could allow access to stronger oral preventives (Topiramate, Beta-blockers, Antidepressants), but this is a very personal choice, balancing maternal health and the baby’s needs.

Non-drug strategies that sometimes help:

Consistent sleep schedule.
Hydration.
Caffeine control.
Identifying food/hormonal triggers.
Relaxation therapy.
Neuromodulation devices (like Cefaly or Nerivio).

Cost is a real concern; if Aimovig is not working, there’s little point in continuing it. Discuss with her neurologist about switching to another CGRP antibody or enrolling in the manufacturer's patient assistance programs.

I hope this answers your query.

Thank you.