Migraine Headache Prevention

Headache Education > Migraine Headaches > Prevention

Before choosing any preventative treatments, it is important to eliminate frequent headache triggers. The most common triggers include irregular sleep, missed meals, caffeine, and chocolate. Other common triggers, which are not preventable, are menstrual cycles, weather fronts, and stress releases.

Once the most common preventable triggers have been eliminated, the next most important step is to make sure headaches are not rebound headaches. Rebound headaches are usually caused by medications that are taken daily. However, any medication that is being more than twice weekly could potentially be causing rebound headaches. Migraine prevention programs are less likely to be successful if a patient continues to take a rebounding medication.

Preventative Medications

The next step is to choose a migraine prevention treatment. Fortunately there are many choices. Four common medications that doctor agree are well proven and highly effective are Elavil® (amitriptylene), Inderal®, (propranolol) Depakote® (valproic acid), and Topamax® (topiramate). Botox is also used if the patient has chronic migraines. The most important thing to remember is that there are numerous agents that one can try for migraine prevention. It is most likely that at least one of them will work well for you. If the first medication does not reduce the number of headaches you are having then don't be discouraged, you may just need a higher dose or you can try a different medication. If you are having frequent headaches, please see your neurologist to discuss possible preventative treatments!

Elavil® (amitriptylene)

The primary advantage of Amitriptylene or Elavil® is its affordability, which can be as low as $5 per month. Unfortunately, Elavil can have numerous side effects, including dry mouth, sedation, constipation, and weight gain.

Inderal® (propranolol)

Another well-established preventative medication is propranolol or Inderal®. This medication is fairly well tolerated in most individuals and is relatively inexpensive, with a twice-daily generic form running about $4 per month. It can worsen asthma, cause fatigue, and limit aerobic exercise. It is generally thought of as a "weight-neutral medication" and most patients do not experience weight gain, but all patients should be monitored for possible weight gain.

Topamax® (topiramate)

Topamax was first licensed as an antiepileptic medication. It is the most popular medication currently prescribed for headache prevention. Among the most commonly prescribed medications, it is the only one that is clearly associated with weight loss. The average obese patient can expect to lose about 10% of their body weight over one year. Since obesity is a risk factor for frequent migraines over time, a large number of migraine patients who need preventatives are medically overweight or obese. Unfortunately, topiramate does have side effects. Some side effects are more of a nuisance. Carbonated drinks taste badly while taking this drug and some patients experience tingling around the mouth, finger, or toes. Renal or kidney stones occur about 1% of the time and do not go away without additional therapy when topiramate is discontinued. A small percentage of patients have an altered ability to think on the medication that commonly expressed as a word-finding problem. This returns to normal with reduction or discontinuation of the medication. Finally, there is a very rare condition of acute narrow angle glaucoma that is very painful but again resolves with discontinuation of the medication and specific medical therapy.

Depakote ER® or valproic acid

The last of the most common preventatives is valproic acid. The most convenient form for patients is Depakote ER®, a once daily migraine prevention agent. Depakote ER® can cause birth defects. In addition, valproic acid can cause weight gain and liver enzyme problems. Despite these warnings, the medication is generally well tolerated and can be used quite safely. However, given the issue with birth defects it is most commonly prescribed to males with migraines who are not overweight. Valproic acid is also widely used as an anticonvulsant to prevent seizures.

Botox (onabotulinum)

Botox is FDA approved for the prevention of headaches in patients with chronic migraine. Because it is one of the more expensive therapies for migraine prevention, it is generally used after patients fail other therapies. Because of its cost, a headache diary should be kept to determine whether the treatment is clearly helpful. The headache diary can also serve as an early warning when the medication is wearing off. The data on botulinum toxin type A or Botox® is quite extensive. Despite this, there continues to be a lot of controversy over its use. It does appear to help some patients with frequent migraines but it remains to be seen how best to choose which patients to treat with Botox®. The cost of the medication is also quite substantial.

Other agents used widely for prevention of migraine include:

Effexor XR® (venlafaxine)

Venlafaxine or Effexor XR® is an antidepressant. Doses of 150 mg or more of this medication have been demonstrated to be a rather robust migraine agent. This medication can have side effects of nausea, sexual dysfunction and sometimes will increase blood pressure.

Cymbalta® (duloxetine)

Another selective serotonin and norepinephrine reuptake inhibitor (SSNRI) on the market is duloxetine or Cymbalta®. It is relatively more balanced than Effexor® and therefore is easier to titrate. It does cause the same amount of nausea as Effexor but is associated with less sexual dysfunction and less hypertension. Cymbalta is FDA-approved in depression, anxiety, diabetic neuropathic pain, chronic low back pain, osteoarthritis pain, and fibromyalgia pain. Since a large percentage of chronic migraine sufferers also have depression, the use of Cymbalta® as a first line agent makes sense and is FDA-approved for their depression.

Verapamil, Coenzyme Q10, Botox® and PFO

There are studies demonstrating verapamil to be a good anti-migraine agent although not as robust as the medications previously mentioned. Coenzyme Q10, which is available over the counter, was demonstrated in one small placebo controlled trial to be beneficial.

Patients with migraines have an increased risk patent foramen ovale (PFO), a small channel between the right atria and left atria of the heart. PFOs in migraine patients also tend to be larger. Some data suggest closing this hole or channel lessens the incidence of migraine. The most important thing to remember is that there are numerous agents that one can try for migraine prevention. It is most likely that at least one of them will work well for you. Unfortunately prevention therapies are under utilized, resulting in excessive disability for migraine patients. If you are having frequent headaches, please see your neurologist and ask to be placed on prevention.

This educational content was written by Brian D. Loftus, MD, a neurologist, headache specialist and developer of iHeadache. The science and study of headaces is changing rapidly. If there is information on this page that is incorrect or needs revision, please contact us.

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