If you get migraines – or have a close friend or family member who does – you may think you already know how to deal with them, or perhaps you have even given up trying to alleviate them. Here's the good news: There are new medications and treatments that can really help, says Dr. Michael Zitney, director of the Headache and Pain Relief Centre in Toronto. Here's what you need to know about managing migraines. • Know your triggers. Some of the most common migraine triggers include hormonal fluctuations, weather changes, stress – or the letdown after stress – red wine, aged cheese, chemicals in food and drink (such as aspartame), strong odours, bright lights, too much or too little sleep, and irritation in your neck or jaw muscles. "Most migraines are not caused by one trigger – it's almost always a combination," says Zitney. While some things, such as the weather, are unavoidable, you can definitely limit your suffering by steering clear of your triggers and adapting your lifestyle. "Most people don't put enough emphasis on the things they can change," he says. • Sign up for weather alerts. A drop in barometric pressure appears to be an important factor for many migraine sufferers. According to a 2009 study in Neurology, it may affect the fluid protecting your brain from the inside of your skull, resulting in increased pressure on external brain tissue. Register for the weather health warning system MediClim (mediclim.com) to receive free email updates about specific weather conditions in your area. "But don't get too obsessed," says Zitney. "If you'e changing the things you can, such as getting more consistent sleep and eating throughout the day, then weather won't be as big of an issue." • Keep a migraine diary. Track your diet, exercise, stress levels and symptoms. It worked for Julie Hewlin, from London, Ont., who now gets four migraines a year instead of 12. After keeping a journal to identify her main triggers, Julie, 38, learned to manage them better by taking walks on her lunch break and getting regular chiropractic adjustments. For a downloadable migraine diary, visit the Headache Network Canada at headachenetwork.ca. • Watch what you eat and drink. Avoid foods that contain chemicals such as MSG and artificial sweeteners. You should generally avoid both red and white wine, too. Yes, it's a drag, but wine can be a trigger because it contains sulfites and preservatives. "If you're going to drink wine, look for organic white wine, which has fewer chemicals, and drink it in moderation," adds Zitney. And take a pass on fruity cocktails, too. They're often loaded with food dyes, preservatives and high-fructose corn syrup, which are all headache triggers, says Dr. Christine Lay, director of the Centre for Headache at Women's College Hospital in Toronto. In addition, the chemicals in steak seasoning and barbecue sauces, and nitrates in meats and smoked meats can also pose a problem, so choose what goes on your plate wisely. If you skip meals or have a serious sweet tooth, it's time to rethink your eating plan. The sugar in carbohydrates causes blood sugar to rise and fall. That roller coaster ride can result in a roaring migraine when you eat too many carbohydrates and not enough protein. To keep your blood sugar levels stable, eat protein-rich foods, healthy fats and lower-glycemic carbs, such as fruits and vegetables, every two to four hours. • Cut back on caffeine. If your coffee habit doesn't seem to affect the number of headaches you get, there's no reason to stop loving those lattes. But if you're regularly drinking caffeine and getting migraines, switch to decaf. Kick your soda and caffeine habit slowly, by gradually switching to drinks that won’t cause migraines, such as mineral water or herbal tea. • Give your senses a break. If you have migraines, you're susceptible to sights and smells, so look for fragrance-free sunblock, insect repellent and skin-care products. • Take your sunglasses with you. Exposure to bright sunlight or glare from the sun's reflection on water or metal can trigger a migraine in some people. Experts aren't sure why this happens, but migraines may be triggered by bright light or glare when it reaches the visual cortex of the brain. • Set your alarm clock. Too much or too little sleep is a huge trigger. Shoot for the same number of hours each night and wake up at the same time daily – yup, even on weekends. To get a good, deep sleep, wind down before bedtime: shut off your Blackberry and get into relaxation mode by reading, meditating or taking a bath. • Exercise your way to fewer migraines. Regular workouts appear to reduce the number and severity of migraines, says Dr. Werner J. Becker, a professor in the departments of clinical neurosciences and medicine at the University of Calgary. Experts aren't exactly sure why exercise reduces migraines, but they do know that it helps keep your weight in check, which is another way to manage migraines: recent studies have linked obesity to migraines. Just make sure you warm up slowly and keep an eye on your posture; if you're straining your neck to read a magazine on the treadmill, it could exacerbate migraine symptoms later. • Take the right medication at the right time. Triptans, such as Imitrex, are widely accepted as the best treatment for migraines. "They can stop a migraine within an hour about 70 per cent of the time," says Zitney. If you take triptans and experience flushing, palpitations and chest pain for more than 30 minutes, get medical help. However, if you don't have high blood pressure, or heart or kidney disease, and have not experienced these side-effects, Zitney recommends giving triptans a try. "There are now seven brands available in Canada, and you should try them all until you find one that is going to help," he says. For the best results, use them correctly: Take the medication as soon as the pain hits. Wait one to two hours for it to work. If you do not experience significant migraine relief, take another painkiller if you feel you need it. If you need to take 10 or more doses of triptans a month, talk to your doctor about preventive medications. • Consider preventive medications. If you have chronic migraines, triptans alone may not be enough – you may need to consider one of the nonmigraine medications that can help reduce the frequency of your migraines. Certain antidepressants, such as amitriptyline, may be helpful because they let your brain release neurotransmitters that help you sleep better, which is a headache-fighting tool. Beta-blockers such as propranolol, which are normally used to treat high blood pressure, may also help ward off migraines. And antiseizure medications, such as topiramate, may also prevent some of the changes in brain chemistry that can cause a migraine headache to start. • Use painkillers effectively. If you're reaching for over-the-counter painkillers, "take a strong enough dose to kill the pain and then lie down and sleep to stop [your headache] from escalating into a three-day migraine," says Zitney. To minimize menstrual migraines, start taking an anti-inflammatory such as ibuprofen or naproxen a few days before your period. To avoid rebound headaches from overusing painkillers, talk to your doctor or pharmacist about the correct dose and taking preventive medications. • Think twice about the pill. For about one-third of women in their 20s and 30s, the estrogen in the contraceptive pill can lead to more migraines, says Lay. If you want to use the pill, she recommends a low-dose monophasic type, which will contain a stable amount of estrogen. If you get migraines around the time of your period, talk to your doctor about taking the pill continuously, so you won't get a period • Book a massage. Strain in your shoulders or neck, from sitting at your desk or driving, may be a trigger. "You may not even notice it that much, but your brain does," says Zitney. Massage can help by relaxing your muscles and reducing the effect of pain on your central nervous system. To keep those upper-body aches and pains from morphing into a migraine, see a massage therapist, chiropractor or physiotherapist, or take up yoga or tai chi, which emphasize good posture and relaxation. "Make sure your massage therapist is experienced with migraine patients," adds Zitney. "If the individual is too aggressive, the treatment can cause a migraine to flare up." • Vitamins and herbs. Certain vitamins and herbs appear to be helpful for warding off migraines, says a 2009 study in the Clinical Journal of Pain. "Correcting all of your vitamin deficiencies and consuming a healthy diet in sufficient quantities (not skipping meals) will help your brain fight off migraines better," adds Zitney. Taking 500 milligrams (mg) of magnesium (a natural muscle relaxant that’s also found in dark leafy greens, nuts and whole grains) may be particularly helpful if you get migraines with your period. If you're not getting enough vitamin B2 (also known as riboflavin) from lean meats, eggs and dairy products, try taking a 400 mg B2 supplement each day. The herb butterbur (50 mg, three times daily, reducing to twice daily) and the nutrient co-enzyme Q10 (300 mg a day) can also be helpful but may be more difficult to find; check with a health food store or naturopath. For each vitamin and herb, start with a low dose and gradually build up to the recommended dose, says Lay. Some studies suggest the herb feverfew may be a good migraine preventive, but Lay doesn't recommend it because it can cause rebound headaches. • Acupuncture. This may also help prevent migraines, according to a 2009 review of studies by researchers at the University of Munich in Germany. But Lay says acupuncture’s effectiveness for preventing chronic migraines is still in question. • Botox. Lay says this neurotoxin is particularly effective for people who get six or more migraines a month; it's injected into the areas where you get migraine pain. The cost varies, but you can expect to pay about $600 per treatment. To treat migraines, most people need Botox injections every 12 weeks, but will eventually be able to reduce that number to twice a year. Studies on the effectiveness of Botox for migraines have had mixed results, but the treatment has been a lifesaver for migraine sufferer Nancy Smith* of Saint John, N.B., who says "the results have been amazing." 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