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Migraine Preventives: Where to Start?

Whether you’ve never taken a >migraine preventive or have tried many, choosing which one to try next can be daunting. A great place to start is with recommendations the American Academy of Neurology and the American Headache Society issued in 2012.1,2

Does research back the recommendations?

Recommendations include both prescription medications and supplements and were based on an extensive review of studies published between 1999 and 2009. Researchers and headache specialists assessed the strength of study findings for each drug and came up with the following list.

Considerations for review

Some things to keep in mind when you review the list:

  • Recommendations are categorized as level A (established as effective), B (probably effective) or C  (possibly effective). Many health care providers will start with level A treatments and work down the list.
  • Generic drug names are listed first with brand names frequently used in the U.S. in parentheses.
  • This project focused on episodic migraine prevention. Many of the drugs and supplements are used for chronic migraine as well, but study participants had episodic migraine. A list of preventives that have been studied and shown to be effective for chronic migraine follows the main list.
  • Beta-blockers, ACE inhibitors, and angiotensin receptor blockers are all drugs for high blood pressure. They’re listed separately because some may be contraindicated for you due to other health issues, while others might be OK.

Level A, established as effective

  • Anticonvulsants: divalproex sodium (Depakote), sodium valproate (Depacon), topiramate (Topamax)
  • Beta blockers: metoprolol (Lopressor, Toprol), propranolol (Inderal), timolol (Blocadren)
  • Triptans: frovatriptan (Frova) – for monthly short-term prevention of menstrually associated migraine
  • Supplements: Petasites (butterbur)

Level B, probably effective

  • Antidepressants: amitriptyline (Elavil), venlafaxine (Effexor)
  • Beta blockers: atenolol (Tenormin), nadolol (Corgard)
  • Triptans: naratriptan (Amerge), zolmitriptan (Zomig) – for monthly short-term prevention of menstrually associated migraine
  • Histamine: subcutaneous histamine injections
  • Supplements: Riboflavin, magnesium, feverfew

Level C, possibly effective

  • ACE inhibitors: lisinopril (Zestril, Prinivil)
  • Angiotensin receptor blockers: candesartan (Atacand)
  • Alpha-agonists: clonidine (Catapres), guanfacine (Tenex, Intuniv)
  • Anticonvulsants: carbamazepine (Tegretol, Equetro)
  • Beta blockers: nebivolol (Bystolic), pindolol (Visken)
  • Antihistamine: cyproheptadine (Periactin)
  • Supplements: Co-Q10, estrogen (could worsen migraines upon withdrawal), phytoestrogen

Chronic migraine prevention

Drugs that have been researched for chronic migraine and shown to be effective include:3

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  • Anticonvulsants: topiramate (Topamax), gabapentin (Neurontin)
  • Antidepressants: amitriptyline (Elavil), fluoxetine (Prozac)
  • Muscle relaxant: tizanidine (Zanaflex)
  • Botox

(All the drugs on the main list are also potentially effective for chronic migraine, but they haven't been studied for it specifically.)

Why aren't all preventives on the list?

There are many other possible preventives that aren’t on this list. Some drugs have shown to be effective in extensive clinical use, but haven’t been researched for financial reasons (it is difficult to recoup the cost of a clinical trial for generic drugs). Others have conflicting evidence in studies, but physicians and patients have learned from experience that they are effective. Still, others were researched before or after the set of studies used in this research.

What if you can't take the recommendations?

Don’t despair! There are more than 100 drugs in use for migraine prevention. You are likely a tougher case than the average migraine patient, so seeing a qualified headache specialist is the best way to find the right treatment(s) for you. Also, it's worth looking into one of the many non-drug therapies that have a good track record for migraine prevention.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

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