Preventive medications are taken daily to prevent migraine attacks from occurring. They are not intended for use to treat the actual headache attack. Also, the choice of a preventive medication needs to be tailored to co-existing medical conditions (such as depression, obesity, anxiety, hypertension, sleep disorders and neuromuscular pains of neck, back and body), possible drug side effects and interaction with other medications that are already being taken. This is why it is important to see a headache professional to help with this important decision to take medications on a daily basis for your migraine. However, even more importantly, the first question that needs to be answered is:
Migraine patients do not want to suffer from any attacks even if from only one a year. However, there are those patients who suffer from frequent or severe attacks and need more aggressive prevention strategies other than trigger avoidance. These preventions sometimes include medication (discussed in this section) but may include procedures (discussed later). Unfortunately, preventive treatment strategies rarely eliminate migraine, but they can reduce the frequency and severity of attacks. Prevention may be warranted if you have:
1. Disabling attacks despite appropriate acute treatment
2. Frequent attacks (>4 per month)
3. Poor tolerance or contraindications for specific acute treatments
4. History of long-term and frequent use of analgesics (OTC or prescriptions) or acute medications that make headaches worse in frequency or severity (or lead to decreased responsiveness to other drug therapies)
5. Neurologic or vascular history that may limit effective abortive strategies
When deciding on preventive therapies, it is important to review with your doctor several important management principles:
Ask your physician what likely benefit you can expect.
Low doses are used at first and gradually increased to higher doses as needed. Therefore, you may need to increase medication dose until the desired response is achieved. This may need to be done slowly as migraine patients are especially sensitive to change in general and to side effects of medications in particular.
Lower dosing frequency is often convenient; however, some medications may need to be taken twice or even three or four times a day to achieve appropriate drug levels while avoid high peak levels that can increase side effects . Discuss the dosing frequency of the medications and make sure it is a plan that you can and will follow. Most studies show that only 50% of the time patients are compliant which is often the biggest reason for initial failure of the treatment.
Some medications work quickly and some may take 2 to 3 months before you notice a decrease in the frequency or severity of attacks even after reaching “the beneficial dose”.
Treatment may be required for 6 to 12 months or longer and unfortunately it may be even years.
There are wide cost differentials in brand versus generic and in insurance coverage and costs factors may unfortunately play a factor in deciding which medication is right for you.
Side effects are common and are to be expected. If you are not tolerating the medication and if you start to have side effects, always contact your doctor to discuss changes to the treatment plan and do not just stop or change medications on your own as this could have significant effects on your health. Even when the plan is to wean off of an effective medication to see if it is still needed, preventive medications need to be gradually tapered off after a period of sustained benefit so that the benefit is not lost.
Preventive drugs can be used as monotherapy (alone) or polytherapy (several different medications). Here are some guiding principles:
1. One drug titrated to the ideal dose (monotherapy)
2. Two drugs are used together (polytherapy), typically from different drug classes (see below), to lessen the maximum dose needed individually that may be associated with an increased risk of side effects associated with each of the medications given in higher doses as monotherapy
3. One drug switched for another drug in order to improve tolerance or efficacy but for a time may be taken together as one is tapered down or off and the other is gradually increased
4. Three or more drugs in either maximal or submaximal doses typically added one after another due to inadequate response or the need for a much quicker result. The risk for side effects is greatly increased, hopefully with a greater and faster efficacy as well, although this is often not the case. Your preferences can strongly influence the selection and speed of this process This is much like a trial and error process ( it may feel that way as well) and may take a while before the desired efficacy is achieved and the side effects are eliminated or at least reduced to acceptable levels.
These are used to treat high blood pressure and can reduce the frequency and severity of migraines. The beta blocker propranolol (Inderal La, Innopran XL, others) has proved effective for preventing migraines. Bystolic is very easily tolerated but more expensive.
Another class of cardiovascular drugs, especially verapamil (Calan, Verelan, others), also may be helpful in preventing migraines and relieving symptoms from aura. However, constipation and dizziness limit compliance with taking this drug.
The antihypertensive medication candesartan (Atacand) has been found useful in reducing the length and severity of migraines. Researchers don't understand exactly why these cardiovascular drugs prevent migraine attacks. Side effects can include dizziness, drowsiness or lightheadedness but it is usually well tolerated even in low blood pressure patients.
Tricyclic antidepressants such as amitriptyline (Elavil), nortriptyline (Pamelor) and protriptyline (Vivactil) are often prescribed for migraine prevention. Tricyclic antidepressants may reduce migraine headaches by affecting the level of serotonin and other brain chemicals, though amitriptyline is the only one proved to be effective for migraine headaches. The doses taken are usually below those used for depression and you don't have to have depression to benefit from these drugs. The major side effect is sedation and weight gain although protriptyline is weight neutral and can disrupt sleep.
Other classes of antidepressants called selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) haven't been proved as effective for migraine headache prevention. However, preliminary research suggests that one SNRI, venlafaxine (Effexor, Venlafaxine HCL), may be helpful in preventing migraines and duloxetine (Cymbalta) may help as well and is effective for the neck and body pain often experienced by migraine sufferers.
Some anti-seizure drugs, such as valproate (Depacon), topiramate (Topamax) and gabapentin (Neurontin), seem to reduce the frequency of migraines. Lamotrigine (Lamictal) may be helpful if you have migraines with aura. In high doses, however, these anti-seizure drugs may cause side effects, such as weight gain, tremor, nausea and vomiting, diarrhea, cramps, hair loss, and dizziness. Valproate should not be given to young children or women of childbearing age. Topamax causes weight loss – one of the only preventative medications that do but it can cause mental dulling and word-finding troubles!
This antihistamine specifically affects serotonin activity. Doctors sometimes give it to children as a preventive measure. There is no good data to support this however. It can causes sedation, dry mouth and weight gain, especially as the child gets older.
The FDA has approved botulinum toxin type A for treatment of chronic migraine headaches in adults. (see the Procedures section)
Magnesium, riboflavin, CoQ10, vit D and fish oil have shown some minimal benefit in some studies and there are minimal side effects at reasonable doses.
Butterber Root (Petadolex) has anti-inflammatory effects and, when made safely, has only abdominal gas as a side effect. However, it may take weeks to months to work.
Estrogen in patch form at appropriate doses may lessen menstrual migraine severity and frequency, however, there are several caveats to this statement.
These may have some role especially during the menstrual cycle.
Frovatriptan (Frova) and possibly naratriptan (Amerge) when taken for a limited time during the menstrual cycle may help prevent migraines.