Migraine Management Essential 4: Preventive Treatment

For anyone who has three or more Migraines a month or whose Migraines are especially severe and debilitating, preventive treatment is an essential element of effective Migraine management.

For some Migraineurs, identifying and managing Migraine triggers can help prevent some Migraines. Unfortunately, for too many of us, trigger avoidance still leaves us with too many Migraines, or our triggers aren’t ones that we can avoid or manage well.

There are more potential preventive treatments than ever before, and an effective preventive regimen can reduce both the frequency and severity of Migraines. Five medications have been officially approved by the FDA for the prevention of Migraine:

  1. propranolol (Inderal);
  2. timolol (Blocadren);
  3. divalproex (Depakote);
  4. topiramate (Topamax); and
  5. onabotulinumtoxin type A (Botox), which is approved for chronic Migraine (Migraine occurring 15 or more days per month) only.

None of those medications were originally developed for Migraine treatment. They were developed for other conditions, then coincidentally found to help prevent Migraines. Before FDA approval, they were prescribed off-label as many medications are today. Off-label prescribing is very common and simply means prescribing medications for conditions other than those for which they’re officially approved.

Today, there are more than 100 medications and dietary supplements in use for the prevention of Migraines and headaches, including:

  • medications originally developed for hypertension or heart conditions:
  • beta blockers: propranolol (Inderal), timolol (Blocadren), and others
  • calcium channel blockers: verapamil (Calan), amlodipine (Norvasc), and others
  • ACE inhibitors: fosinipril (Monopril), enalapril (Vasotec), and others
  • Alpha-2 agonists: clonidine (Catapres), guanfacine (Tenex)
  • Angiotensin II inhibitors: candesartan (Atacand); almesartan (Benicar), and others
  • antihistamines:
  • cyproheptadine (Periactin)
  • pizotifen (Sandomigran, available in UK only)
  • antidepressants
  • tricyclic antidepressants such as amitriptyline (Elavil), nortriptyline (Pamelor), and others
  • SSRI antidepressants such as paroxetine (Paxil), citalopram (Celexa), and others
  • SNRI antidepressants such as venlafaxine (Effexor) and duloxetine (Cymbalta)
  • MAOI antidepressants such as isocarboxazid (Marplan) and phenelzine (Nardil)
  • memantine (Namenda), which was originally developed for Alzheimer’s Disease
  • medications originally developed for attention deficit hyperactivity disorder (ADHD), including dextroamphetamine (Adderal), and atomoxetine HCL (Strattera)
  • muscle relaxants such as tizanidine (Zanaflex), carisoprodol (Soma), and others
  • neuronal stabilizing agents, commonly called anticonvulsants, including divalproex (Depakote), gabapentin (Neurontin), topiramate (Topamax), and others
  • leukotrine blockers originally developed for asthma including montelukast (Singulair) and zafirlukast (Accolate)
  • neurotoxins: onabotulinumtoxin type A (Botox)
  • dietary supplements:
  • Medical Devices: The NTI Tension Suppression System (NTI-TSS) is a dental appliance that has proven to be effective for some people for whom clenching or grinding their teeth is a Migraine trigger.

It’s important to know that it can take up to three months to give a preventive medication a fair trial and know if it’s going to work for an individual or not, and what works varies widely from one person to the next.

For some people who need preventive treatment, one medication or supplement is adequate. However, many Migraineurs will find more than one that works, but none work well enough alone, so they work with their doctors to develop a preventive treatment regimen that’s a combination of two or more medications or supplements.

If you’re having three more Migraines a month, or if your Migraines are especially severe or debilitating, please talk with your doctor about preventive treatments. With so many options, it’s no longer necessary to “just live with” frequent or severe Migraines. It may take time and patience to find the right treatment regimen, but it’s well worth it.

Many family doctors and general neurologists have at least some understanding of and experience in treating Migraine and will be able to suggest some preventive treatments. They are, however, usually not familiar with the full range of possibilities for preventive treatments. Should this be the case with your doctors, don’t lose hope. There are Migraine specialists whose practices are limited to treating patients with Migraine and other headache disorders, and these specialists are better versed in preventive treatments..

Learn more about migraine treatment options:

For a more complete listing of potential Migraine preventives, see Migraine and Headache Preventives: It’s Impossible to Have Tried Everything!

FDA News Release. "FDA approves Botox to treat chronic migraine." U.S. Food and Drug Administration. October 15, 2010. - News Release. "FDA approves Botox for Migraine headaches." Associated Press. October 15, 2010. - Friden, Joyce. "FDA Okays Botox to Prevent Migraines." MedPage Today. October 15, 2010. - Interview: Teri Robert with Dr. Stephen D. Silberstein. October 17, 2010. - Interview: Teri Robert with Dr. Fred Sheftell. October 18, 2010. - Rozen, TD, Oshinsky, ML, Gebeline, CA, Bradley, KC, Young, WB, Shechter, AL & Silberstein, SD. "Open label trial of coenzyme Q10 as a migraine preventive." Cephalalgia22 (2), 137-141. - Andrew D. Hershey MD, PhD; Scott W. Powers PhD; Anna-Liisa B. Vockell RN, MSN, CPNP; Susan L. LeCates RN, MSN, CFNP; Priscilla L. Ellinor RN, MSN, CPNP; Ann Segers RN, Danny Burdine BA; Paula Manning RN; Marielle A. Kabbouche MD (2007). "Coenzyme Q10 Deficiency and Response to Supplementation in Pediatric and Adolescent Migraine." Headache47(1), 73—80 doi:10.1111/j.1526-4610.2007.00652.x - Ramadan, Nahib M., MD; Silberstein, Stephen D., MD, FACP; Frietag, Frederick G., DO; Gilbert, Thomas T., MD, MPH; Frishberg, Benjamin M., MD. "Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management for Prevention of Migraine." American Academy of Neurology Practice Guidelines. September, 2000.

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