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New migraine prevention recommendations from the AAN

This week, neurologists and headache specialists from across the country have convened in New Orleans for the annual meeting of the American Academy of Neurology to hear the latest breakthroughs and recommendations for treating neurological conditions, like migraine.

At this year’s meeting, attendees will be among the first to hear about new migraine recommendations that were just published in the journal Neurology.1 These guidelines target prevention drug therapy for patients with episodic migraine. Episodic migraine is defined as migraine typically occurring less than 15 days per month. When migraine occurs more frequently, it’s called chronic migraine. This distinction is relatively new and fewer studies have tested migraine prevention therapies in patients with chronic migraine. The current guidelines, therefore, focus on treatment of patients with frequent episodic migraines. The guidelines do not address non-drug treatments that might effectively reduce migraine frequency or severity, like relaxation, biofeedback, stress management, exercise, etc. The guidelines also don’t address botox as a prevention therapy, with a notation that botox will be addressed in a subsequently published report.

In general, migraine prevention is considered when people regularly experience more than a couple migraines each week or migraines don’t respond to acute management. It’s estimated that about two of five people with migraine would benefit from prevention therapy. Unfortunately, only about half of those who are candidates are prescribed preventive treatments. Migraine prevention can include both drug and non-drug treatments and studies show that people tend to get the best relief when including non-drug treatments along with their medication therapies.

New recommendations developed by the American Academy of Neurology and American Headache Society (Pharmacologic Treatment For Episodic Migraine Prevention in Adults) include traditional medication and complementary drug treatments. Here’s a summary of important new recommendations just published in Neurology:

Migraine prevention drugs

These recommendations address prescription drugs that are traditionally used for migraine prevention.

  • Drugs that have the strongest evidence supporting their effectiveness as migraine prevention include: antiepileptic drugs (valproate and topiramate) and beta-blockers (metoprolol, propranolol, timolol). There’s also strong evidence supporting frovatriptan as short-term prevention for menstrual migraines.
  • Drugs that are probably effective preventives, although the evidence is not as strong, include: antidepressants (amitriptyline and venlafaxine) and some other beta-blockers (atenolol and nadolol). Naratriptan and zolmitriptan may be effective preventives for menstrual migraine.
  • Other drugs commonly used for migraine prevention, like calcium channel blockers and other antihypertensives, newer antidepressants (like selective serotonin reuptake inhibitors and selective serotonin-norepinephrine reuptake inhibitors) and gabapentin don’t have strong evidence supporting their benefit as migraine prevention therapies.
  • The antiepilepsy drug lamotrigine and the antidepressant clomipramine have been shown to be ineffective for migraine prevention.

Patient tools describing recommendations, including a podcast, can be accessed online at the American Academy of Neurology website.

The new recommendations reinforce that, unfortunately, finding the best drug for the individual patient often requires trying several drugs before the best match is found. It’s also important to consider your other health conditions and which side effects are most likely to be bothersome to you when selecting specific treatments for you.

Nonsteroidal anti-inflammatory (ibuprofen-like) drugs and complementary treatments for migraine prevention2

These recommendations address the use of over-the-counter and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) and herbal or nutritional therapies for migraine prevention.

  • Petasites (or butterbur) has strong evidence that it is an effective migraine prevention therapy.
  • Therapies that are also probably effective migraine preventives include: riboflavin, magnesium, feverfew, some NSAIDs (fenoprofen, ibuprofen, ketoprofen, and naproxen), and subcutaneous histamine injections.
  • Strong evidence is lacking to support migraine prevention benefits from coenzyme Q10 and omega-3.
  • The asthma medication montelukast is ineffective as a migraine prevention therapy.

Although NSAIDs can effectively prevent migraine, long-term daily use can result in medication overuse headache, especially with ibuprofen. In addition, long-term regular use of NSAIDs is generally discouraged due to concerns about side effects, such as stomach and kidney toxicity.

What about chronic migraine?

The current guidelines do not directly address chronic migraine treatment. A recent report from the Mayo Clinic published in the journal Seminars in Neurology provided a summary of studies where drug prevention was specifically targeted in people with chronic migraine. Drugs that were shown to be effective for chronic migraine in controlled, randomized research studies included:

  • Antiepileptic drugs topiramate and gabapentin
  • Antidepressants amitriptyline and fluoxetine
  • Muscle relaxant tizanidine

Botox is also approved for the prevention treatment of chronic migraine. The National Institutes of Health is currently conducting a study to test the benefits of a low omega-3 (avoid most oils; add vegetarian meals, lean fish, egg whites)/high omega-6 diet (add flaxseed and fatty fish [canned tuna, salmon, trout] for reducing chronic daily headache, with results expected in 2013

References 1. Silberstein SD, Holland S,Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults. Neurology 2012;78:1337-1345.2.Holland S, Silberstein SD, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012;78:1346—1353

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.


  • Brian in TN
    6 years ago

    Slightly disturbing / depressing that amatriptyline is so well reviewed considering what my research revealed. It is only helpful for 10% of patients, the same as chiropractic, and has obnoxious side effects such as sensitivity to sunlight (feels like you already have a bad sunburn) lethargy, confusion, insomnia. It’s also very dangerous to children, a neurologist in Jacksonville, FL told me he won’t prescribe it to anyone in a household with children under 12, or a home where children visit often. In the 4 cases he was called in on with children accidentally poisoned with Elavil the BEST result was the one child who could still donate her organs! All 4 were fatalities. I was convinced that the Navy only requires 6 months of Elavil therapy to convince sailors that migraine treatment is worse than the migraines themselves.

  • kallengar
    6 years ago

    There is an error at the end of this article….should read high omega 3, not LOW omega 3. Then, low omega 6, and NOT low omega 3. The typical north american diet has too much omega six fatty acids and not enough omega 3 fatty acids, so what the article says should be reversed.

  • AmyBabee
    6 years ago

    Tried hormonal treatment of different kinds and none helped. Right now we are still trying some other 12-weekly hormonal shots treatment to stop my period from coming every month; my period stopped alright but headache is still there every blessed day!

  • Nancy Harris Bonk moderator
    6 years ago

    Hi AmyBabee,

    Hormones can certainly trigger a migraine for many of us. I’m not sure if you saw this in the above information; “There’s also strong evidence supporting frovatriptan as short-term prevention for menstrual migraines.” It may be a conversation for you and your doctor.


  • Bill Eickelberg
    6 years ago
  • Calvin Hunter
    7 years ago

    The 2 most effective treatments are avoiding the triggers and oxygen therapy.

  • Newdancerco
    6 years ago

    Perhaos for you oxygen worked. For me it was useless, and I was at altitude at the time (lived in the mountains a mile above sea level then). I tried for about 6 months before I gave up and admitted it wasn’t helping anything.

    Butterbur I may try again, though…

  • Chad Whyte
    7 years ago

    Now these are guidelines based on evidence. That doesn’t mean that certain drugs do not work, it’s just that there haven’t been enough significant studies that show they do. For example, I think gabapentin is a lot better than evidence shows.

  • Teri Robert
    7 years ago

    Thanks for that comment, Dr. White. For years, we’ve been using verapamil and there’s been a body of thought that it’s one of the best for hemiplegic Migraine, but it didn’t fare very well in the guidelines either.

  • Christopher Hicks
    7 years ago

    Drugs, drugs, drugs. I have been working with a neurologist for years. His treatment is medication. He is part of a team at a clinic that does offer a few other options but most those have been ruled out because my headaches are focused more in the front and on top of my head rather than the back or in my neck.
    So, I am on and have been on so many different medications that we are now circling back on things I was taking years ago to “see if they work this time”.
    The only other option offerred at this clinic is Botox, which I have tried once before with no benefit.
    It is interesting to read some of the other responses here. I have, lately, been thinking a lot about diet. I have tried to alter my diet in the past but I am beginning to think I may not have been aggressive enough (cutting out all dairy, animal protein, sugar, caffeine, etc.).
    It is nice to read the responses and to see that there is some hope out there! Thanks to those who contribute.

  • Newdancerco
    6 years ago

    If you haven’t, consider trying botox again. My neurologist in CO showed me studies indicating that, in a small but significant number of people, the first round doesn’t work but subsequent rounds become more effective. This was the first time I had it, so maybe 8 years ago, and my first round hadn’t done any good. The second was better, and I had it regularly until I got pregnant. Sadly, it hasn’t worked as well since…
    If you only had one round of shots, you *might* have stopped too soon.

  • Melanie Symonds
    7 years ago

    I wonder why the hormones Progesterone and Estradiol aren’t even mentioned for managing menstrual/perimenopausal migraine? Of all the preventives I’ve ever tried, they’ve been the most effective by far.

    Also, contrary to the above, I’ve seen substantial benefit from Coenzyme Q10. It clearly reduces the intensity of my pain, along with Magnesium and the full complex of B-vitamins (not just B2/Riboflavin.)

  • Michelle Doyle
    7 years ago

    Will share with Family doctor regarding my Chronic Migraines… Thank you!

  • Barbetta Reedy
    7 years ago

    I like to know which drug do you go on when you reach 60 yrs of age when they will not let you have the sumatriptan shots which I am on and it takes my migraine away. I have been on all sorts of meds because I have had my migraines now for 38 yrs and the only thing that did work was imitrex. All the anti-depressants and channel blockers did for me was weight gain and I refuse to take them because of this side effect I don’t want to be this big.

  • Jaylene Ancheta
    7 years ago

    None of the medications listed ever helped me at all. They all made my migraines worse. I’m am finally out of the chronic migraine stage though. For me, Prolotherapy, 5-HTP, and a natural wholesome (mostly raw food) diet is what worked. The only thing that really triggers a bad and instant migraine in me now is over stress. I have to really avoid becoming upset or crying…not always an easy thing to do.

  • Nermeen Altaher
    7 years ago

    Botox is my magical potion!

  • Nermeen Altaher
    7 years ago

    Barbetta Reedy My dermatologist uses it around hairline all over my head spacing shots and on the back of my neck try a different doctor and give ur kidneys some rest from all the other drugs.

  • Barbetta Reedy
    7 years ago

    all botox did for me is give me acid reflux disease which is a side effect from it, using it too close to my throat

  • Julie Cramer Avenick
    7 years ago

    Topomax did wonders for my chronic migraines but also gave me kidney stones. I wish they could find the right match for me so I can stop suffering.

  • Newdancerco
    6 years ago

    Try zonisamide, a drug similar to topamax with just slightly different side effects. Topamax made me dumb (word finding became well nigh impossible), but zonisamide has been no problem.

  • Marquita Fuchs
    7 years ago

    Topamax may help migraines but we call it the stupid drug. It effects memory.

  • Newdancerco
    6 years ago

    We called it “Dopamax”. I was on it over 6 uears ago, got to the point I couldn’t do things like order a meal at dinner or complete a sentence!

    I never got my brain back to where it should be, even all these years later.

  • Best Dessert First
    7 years ago

    yes it does I was on it for some time without knowing about the memory problems.I stoped taking it when i starting having nightmares very bad ones and seeing things that were not there felt like I was going crazy and was lucky if I could remember my own name. I will never take this again.

  • Janet Sweet
    7 years ago

    i took topamax…they don’t like to be told it effects memory, or for me it ruined my vision, had a friend lose her sight for 3 days and the enamel from my teeth was being effected. i was asked “well, do you want the migraines or not?” stupid drug…that’s putting it mildly.

  • Barbetta Reedy
    7 years ago

    topamax takes your concentration away after being on it for 5 yrs I am still having the problems of that drug when I told my dr that I had problems remembering he took me off instantly been off now for 5 yrs now but like I said before still having problems with that drug

  • Alli Eisele Siringo
    7 years ago
  • La Diosa
    7 years ago

    do a study and make everyone Vegan for a week and see how many chronic migraine suffers u help… It changed my life, I suffered daily massive chronic migraines and no drugs helped ever.. The reason no drugs ever help and only made it worse was because of the dairy added in the prescription medications that were suppose to help me.. All the doctors thought I was crazy just because I would tell them no the medication didn’t help it made it worse and it gave me a headache if there wasnt one there… Who know that all dairy, even if its a little can cause such big problems with migraines… Good luck to everyone who doesn’t have an answer yet…

  • mgh4348
    6 years ago

    Check out a Paleo diet – mainly animal protein and veggies, what humans evolved on as hunter/gatherers (no grains). A vegan diet will not supply what your body needs long term for health.

  • Anne-Marie Allen
    7 years ago

    that is quite interesting

  • Chris Waters
    7 years ago check this out great treatment for migrains.

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