When to Start Preventive Therapy for Migraine

Preventive therapy is daily medication for patients who:

Experience 3-4 or more migraines per month

Present with medication overuse headache

Who prefer this type of treatment 

Have significant pain that hampers their life.

Take a lot of over the counter, narcotic, opioid or barbiturate pain killers

Don’t get enough relief from the medications they are currently taking

Have side effects from drugs used for acute therapy

Preventive treatment might not be an option for patients who:

Can control their headaches with anti-inflammatory drugs (NSAIDS) like naproxen or ipuprofen

Have other health conditions that don’t allow taking preventive drugs

Might have preventive drugs that don’t mix well with the other medications they take

Prefer treatments that don’t involve taking medications

Can get relief from relaxation therapy, stress-management, or biofeedback

Prefer a medical device called Cefaly, which is an FDA approved treatment for migraine prevention.  It is worn on the head, delivers electrical impulses, and is used once a day for 20 minutes.

Are pregnant, as migraine usually improves in the 2nd or 3rd trimesters

American Academy of Neurology and American Headache Association recommendations for preventive drugs:

Level A established as effective--Divalproex sodium, sodium valproate, Topamax (topiramate), Trokendi XR, Qudexy XR, Frovatriptan (long acting triptan--26 hours) for menstrually related migraine short term,

OnabotulinumtoxinA (Botox)--physician injects onabotulinumtoxinA into the muscles of the forehead and neck.  When effective, the treatment is repeated every 3 months.  Indicated for persons with Chronic Migraine (15 headache days/month, 8 of which are like migraine)

Metoprolol, propranolol, timolol, frovatriptan

Level B—probably effective—amitriptyline, nortriptyline, venlafaxine

Level C—possibly effective ACE inhibitors (Lisinopril), angiotensin receptor blockers (candesartan), alpha-agonists (clonidine), carbamazepine

Level A: established as effective; should be offered to patients requiring migraine prophylaxis

Divalproex/sodium valproate 400-1000 mg/day

Metoprolol 47.5-200 mg/day

Petasites (butterbur) 50-75 mg bid

Propranolol 120-240 mg/day

Timolol 10-15 mg bid

Topiramate—Topamax, Qudexy XR, Trokendia XR 25-200 mg/day

Level B: probably effective; should be considered for patients requiring migraine prophylaxis

Amitriptyline 25-150 mg/day

Fenoprofen 200-600 mg tid

Feverfew 50-300 mg bid; 2.08-18.75 mg tid for MIG-99 preparation

Histamine 1-10 ng subcutaneously twice a week

Ibuprofen 200 mg bid

Ketoprofen 50 mg tid

Magnesium 600 mg trigmagnesium dicitrate qd

Naproxen/naproxen sodium 500-1100 mg/day for naproxen 550 mg bid for naproxen sodium

Riboflavin 400 mg/day

Venlafaxine 150 mg extended release/day

Atenolol 100 mg/day

Level C: possibly effective; may be considered for patients requiring migraine prophylaxis

Candesartan 16 mg/day

Carbamazepine 600 mg/day

Clonidine 0.75-0.15 mg/day; patch formulations also studied

Guanfacine 0.5-1 mg/day

Lisinopril 10-20 mg/day

Nebivolol 5 mg/day

Pindolol 10 mg/day

Flurbiprofen 200 mg/day, 500 mg tid

Coenzyme Q10 100 mg tid

Cyproheptadine 4 mg/day

General statement

All of the listed drugs above for prevention may reduce headache significantly.  However, there are special considerations for patients with multiple medical problems using these drugs.  Patients who are anxious and can’t sleep or have depression may be given amitriptyline or nortriptyline.  Amitriptyline is also the go to drug for patients who have limited funds or no insurance drug coverage since it is so cheap, often just 3-4 dollars a month.  Persons who have epilepsy and migraine and overweight should be offered topiramate but this drug shouldn’t be given to patients with a history of kidney stones.  Patients with tremor, hypertension, or migraine may be given a beta blocker which may treat all three conditions.  Thinking this way, the doctor and the patient may get a double treatment effect from a single preventive medication.