Prevention
Lifestyle measures and non-drug approaches, such as biofeedback, should be tried first for preventing migraine attacks.
In general, patients should discuss using medications on a daily bases for prevention of migraines when one or more of the following conditions are present:
- When recurring migraines significantly interfere with normal activities, even with treatment.
- If attacks are severe and disabling.
- If drugs used for migraine attack are ineffective.
- If drugs used for treatment are being overused.
- If side effects of treatment are overly severe.
- If migraine attacks are frequent (typically striking more than two or three times a month).
- If the migraines are rare forms (for example, hemiplegic migraine, basilar migraine, migraine with prolonged aura). It is important to determine the migraine type because some of the standard drugs for migraines, such as triptans, are not effective with hemiplegic and basilar migraines.
Specific Approach. In most cases, the patient takes medications in the following manner:
- One agent is usually tested at a time, with the patient taking the least powerful drug at the lowest dose first and increasing to greatest potency as agents fails.
- Combinations may be appropriate (such as a nonsteroidal anti-inflammatory drug [NSAID] with an antidepressant) for certain individuals.
- Patients who have certain other medical conditions (e.g., heart disease, history of stroke, epilepsy, anxiety) may be able to choose drugs that are useful for both conditions. (For example, beta-blockers are used for many heart conditions and valproate is also a drug used in epilepsy.)
- Patients should use a headache diary to evaluate the effects. It may take two to three months for the patients to experience benefits from a preventive program.
- Once a medication has controlled the migraine, the patient should try tapering the dose after six to 12 months, with the goal of stopping completely.
It should be noted that many of these preventive drugs have potentially serious side effects, and that even with their use, only 10% of patients become completely headache free. (Medications should never be taken as preventive measures for tension-type headaches, except for unusual chronic or very predictable types. In these cases, a physician should always be consulted.)
Migraine Medications Commonly Used for Prevention
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Drugs
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Used for Prevention
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Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin, ibuprofen (Advil), and naproxen (Anaprox, Aleve).
Potent prescription NSAIDs are available.
COX-2 inhibitors are possible options.
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Low-dose aspirin or other over-the-counter NSAIDs, effective for prevention in 20% of cases.
Prescription-strength NSAIDs reported to be effective in reducing frequency of attacks in 50% of patients.
Disadvantage: Gastrointestinal problems, including possible bleeding, with long-term use. (COX-2 inhibitors may have fewer GI problems.)
Rebound Effect.
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Antidepressants (tricyclics, SSRIs).
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Tricyclics (especially amitriptyline) are particularly useful for combination headaches. They cause frequent side effects, however. SSRIs and newer antidepressants may be helpful in some circumstances, although evidence is weak.
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Beta-blockers (propranolol).
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Reduce frequency of attacks and severity when they occur.
Disadvantage. Should not be used with patients with asthma and certain heart conditions. Used with caution in those with diabetes.
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Valproate (Depakote), gabapentin (Neurontin), topiramate (Topamax) or other anticonvulsant agents.
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Valproate is the first drug specifically approved for prevention of migraines. They reduce frequency of attacks and severity of migraines without auras. They are expensive and can have severe side effects. Not generally recommended as first-line prevention. May be useful for patients who cannot take medications that constrict blood vessels.
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Calcium-Channel blockers (diltiazem, nimodipine, verapamil, flunarizine).
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Prevent migraines and cluster. May be particularly useful in migraine patients at risk for stroke.
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