Your Practical Guide to Migraine Preventive Medications

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While over 1 billion people world wide have migraine, only a small percentage of them use migraine preventive medications to control their migraine attacks. A migraine preventive medication is considered and offered when people with migraine meet certain criteria:

Four or more attacks per month or eight head pain days – Can include severe throbbing pain or a pulsing sensation, usually (but not always) on one side of the head. It is often accompanied by nausea, vomiting, and sensitivity to light and sound. Migraine attacks typically last for 4-72 hours, and the pain can be so severe that it interferes with daily activities. Vestibular migraine attacks might not have head pain, but will include vertigo, dizziness, Alice in Wonderland syndrome among other symptoms.
Significantly disabling attacks.
Attacks lasting longer than three days.
Acute medications are not helpful.
Triptans are contraindicated or poorly tolerated.
Use of acute pain medication on more than three days per week.
Have menstrual migraine.
Have hemiplegic migraine, migraine with brainstem aura, aura that is prolonged or uncomfortable and migrainous stroke.

The American Migraine Prevalence and Prevention (AMPP) study found that only 13% of all patients with migraine currently use a preventive medication or therapy to control their migraine attacks. (1) ‘The World Health Organization now ranks migraine as the third most prevalent medical condition in the world, and the second most disabling neurological condition. The economic cost of migraine is also considerable and has an estimated worldwide annual cost of $20 billion, relating to healthcare, procedures and loss of productivity.’ (2)

Intent Of This Article

The intent of this article is to compile the most commonly prescribed migraine preventive medications in one place for easy reference. This is by no means an exhaustive list. Each of the writers for Migraine Strong experience different types of migraine and have different, and effective, preventive strategies. I’ll go over those at the end of the article to give an idea of how we work with our doctors to manage migraine.

** Disclaimer: This is written from the perspective of the patient and patient-advocate. This is not a substitute for medical advice. The information here will help you understand your many options so that you are better prepared for the next conversation you have with your healthcare provider.

Preventive Medications for Migraine

The goal of using a migraine preventive medication is to reduce the severity or frequency of attacks by 50% within the first three months. The medication could also reduce the length of attacks, increase the response to acute medications, decrease disability and increase function. While many patients find relief with just one medication (monotherapy), some require more than one medication (polytherapy) to achieve the 50% reduction in symptoms. Doctors will also prescribe some of the medications below based on co-occurring conditions such as depression, anxiety, insomnia or high blood pressure to treat both conditions at once.

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Starting a preventive medication

When beginning a preventive medication for migraine, it is best to start at a low dose and increase slowly. This conservative approach can reduce or eliminate side effects and make medications more tolerable and effective. (3) We have especially found this to be true with the people who have vestibular migraine in our community. The slower titration that is used, the more likely it is we will tolerate the medication. It’s not a guarantee, but it is more effective than starting at a higher dose which is not tolerated at all and then the medication is abandoned.

Vestibular Migraine

Dr. Timothy Hain is a leading authority in treating vestibular migraine and other dizzy disorders. I have included his flowchart here as an example of how vestibular migraine can be treated. If you are struggling with vestibular migraine, see if this flowcharts sheds any light on a different line of attack. Many of the VM members of Migraine Strong have found relief with starting the Heal Your Headache diet.

Dr. Shin Beh published a book titled Victory Over Vestibular Migraine: The ACTION plan for healing and getting your life back which might be helpful to many with vestibular migraine. The book discusses not only preventive medications but also supplements, lifestyle changes and diet as a way to manage vestibular migraine. It was a very informative read and we recommend it for anyone struggling with vestibular migraine.

Preventive Treatments for Migraine

Below are tables of medications broken into specific groups. Dosages will vary and it is always a good idea to check with your pharmacist or an online medication checker to see if your dosage is in line with common practice. Do not change the dosage of your medication without first checking with your doctor. The online checkers give guidelines based on common prescribing practices and your dose might be dependent on other variables if they don’t match up.

Beta blockers for migraine

Propanolol is a commonly used preventive medication for migraine. ‘It acts by blocking beta-adrenergic-mediated cerebral vasodilation’ (4). Some of the medications listed below are not FDA approved for the treatment of migraine, but they are widely accepted as effective. ‘Side effects include fatigue, depression, nausea, dizziness and insomnia; however, symptoms appear to be fairly well tolerated.’ (5)

There are several beta blockers commonly used for migraine. They are often the first line of preventives tried, especially for those with high blood pressure.

Beta Blockers	Brand Name
Propanolol	Generic
Nadolol	Corgard, Generic
Atenolol	Tenormin, Generic
Metroprolol	Toprol XR, Lopressor, Generic
Timolol	Betim, Generic

CGRP antagonists for migraine

Over the last year, many new migraine specific medications have come to the market. These include all of the monoclonal antibody injections and IV medication. These medications specifically target calcitonin gene related peptide (CGRP) levels which increase during attacks in migraine patients. (6) These medications target the peptide itself or the CGRP receptor. CGRP antagonists for migraine have been a useful tool for many living with migraine.

Injections	Brand Name
eptinezumab-jjmr	Vyepti
Erenumab	Aimovig
Fremanezumab	Ajovy
Galcanzumab	Emgality
Atogepant	Qulipta
Rimegepant	Nurtec

Botox and nerve blocks

OnabotulinumtoxA (Botox) is generally well tolerated for the treatment of migraine. While we don’t know the exact method for how it works on migraine, it will generally prevent 8-9 headache and migraine days per month. This in depth review of Botox for migraine is very informative.

Injection	Brand Name
OnabotulinumtoxinA	Botox
Greater Occipital Nerve Blocks

ACE inhibitor and ARB’s

“ARBs and ACE inhibitors are thought to prevent the occurrence of migraine through a number of mechanisms that include promotion of vasoconstriction and reduction in pro-inflammatory cytokine levels.” (7) These medications are well tolerated and are also less expensive than many other migraine preventive medications.

Angiotensin-converting enzyme (ACE) Inhibitors, Angiotensin II receptor blocker (ARB)	Brand Name
Candesarten	Atacand, Generic
Lisinopril	Zestril, Prinvil, Generic

Calcium channel blockers for migraine

Verapamil appears to be effective for the prevention of migraine, but is not FDA approved for it. Flunarazine is available in some European countries, and is approved for the prevention of migraine. (8)

Calcium Channel Antagonists	Brand Name
Flunarazine (not available in the US)	Sibelium
Verapamil	Verelan PM, Verelan DR, Calan, CalanSR, Generic
Diltiazem	Cardizem

Antidepressants for migraine

Antidepressants can be broken down into three categories, tricyclics, Selective Serontonin Reuptake Inhibitor (SSRIs) and Selective Serotonin/Norepinephrine Reuptake Inhibitor (SNRIs). While it’s unclear why, some seem to be more effective than others in migraine prevention.

Tricyclics

Amitriptyline is the only tricyclic antidepressant that has been shown to be consistently effective for the treatment of migraine and chronic tension-type headache. Sometimes amitriptyline has a side effect profile that patients find unfavorable (specifically weight gain), so nortriptyline is often prescribed instead. The drawback here is that it is not as well studied as amitriptyline as a headache preventive. Even so many choose nortriptyline over amitriptyline for it’s lower side effect profile. A positive side effect of both is that they can often help with sleep as well.

SSRIs & SNRIs

According to a 2011 CNS Neuroscience study, “Migraine and chronic tension-type headache patients are between two and five times more likely to suffer from a depressive or anxiety disorder than are individuals without headache”. (9) Treating co-morbid conditions of depression, anxiety and migraine can be a benefit of adding an antidepressant to migraine prevention therapy. While the SSRI’s and SNRI’s can help manage depression and anxiety, in some people it can also increase head pain. (10)

Being aware of this potential positive side effect can help patients and doctors make decisions about which medications (shown below) (11) to use and at what dose to be effective for both migraine and depression and/or anxiety. Most have shown to not be effective as a standalone treatment for migraine AND depression/anxiety.

Instead it is recommended “SSRI use should be limited to the treatment of depression or anxiety in the headache patient, but not primarily as headache preventives.” (12) The main SNRI medication that helps those with vestibular migraine is venlafaxine. This is often prescribed as a first line medication along with tricyclic antidepressants. Dr. Timothy Hain talks about treating vestibular migraine with these medications on his website.

Tricyclic Antidepressants	Brand Name
Amitriptyline	Elavil
Nortriptyline	Pamelor
Protriptyline
Doxepin	Sinequan

Selective Serontonin Reuptake Inhibitor (SSRI)	Brand Name
Citalopram	Celexa
Escitalopram	Lexapro
Fluoxetine	Prozac
Paroxetine	Paxil, Pexeva
Sertraline	Zoloft

Selective Serotonin/Norepinephrine Reuptake Inhibitor (SNRI)	Brand Name
Venlafaxine	Effexor
Duloxetine	Cymbalta
Desfenlafaxine	Pristiq

Anticonvulsants for migraine

Topiramate, sodium valproate and gabapentin have all shown to be effective in reducing the frequency and severity of migraine attacks. Lamotrigine has also been shown to be effective at reducing the severity of aura and the attack frequency for patients who have migraine with aura. (13)

While all of the listed anticonvulsants have demonstrated effectiveness with the treatment of migraine to some degree, some side effects make them less likely to be continued by patients. (14) Starting at a low dose and increasing slowly may mitigate some of the side effects and make the medications more tolerable. This review of Topamax for migraine is very helpful in cutting through some of the confusion about this medication found on social media.

Anticonvulsants for migraine, especially topiramate and sodium valproate are commonly prescribed and sometimes required by insurance companies before approval of more expensive medications.

Anticonvulsants	Brand Name
Topiramate, Topiramate XR	Topamax, Topamax XR, Generic
Sodium Valproate	Depakote, Epilim, Epilim Chrono, Episenta, Generic
Gabapentin	Neurontin
Pregabalin	Lyrica
Zonisamide	Zonegran
Levetiracetam	Keppra
Lamotrigine	Lamictal

Muscle relaxers for migraine

These medications have very good efficacy for preventing migraine and little side effects besides sedation. “Muscle relaxants do more than just relax muscles – they actually work on brain mechanisms of migraines.” (15)

Since sleep is often a problem for people with migraine, muscle relaxers for migraine can sometimes help with both.

Muscle Relaxants	Brand Name
Cyclobenzaprine	Flexeril
Tizanidine	Zanaflex
Baclofen	Lioresal

NSAIDs and triptan for menstrual migraine

Menstrual migraine can be one of the most difficult to treat. The medications listed below are effective in treating menstrual migraine, however following the dosing schedule requires being able to predict the start of the menstrual cycle. Two days prior to the menstrual cycle starting, the medications can be taken twice daily and continue that dosing schedule for 5-7 days depending on the medication prescribed. Five days for naproxen/naproxen sodium, naratriptan and low dose sumatriptan, six days for frovatriptan and seven days for zolmitriptan. (16)

NSAIDs and Triptans	Brand Name
Naproxen/Naproxen Sodium	Naprosyn/Aleve
Frovatriptan	Frova, Generic
Naratriptan	Amerge
Sumatriptan	Imitrex, Generic
Zolmitriptan	Zomig

Miscellaneous Medications

There are some medications that fall into the miscellaneous category. Acetazolamide has been shown to help with migraine attacks associated with flying and altitude as well as those triggered by barometric pressure fluctuations. (17) Spironolactone has been shown to reduce the frequency and severity of migraine that is co-morbid with fibromyalgia. (18) Memantine also reduces the frequency and severity of migraine and is effective when added on to other therapies. (19)

Miscellaneous Medications	Brand Name
Acetazolamide	Diamox
Spironolactone	Aldactone
Memantine	Namenda

Nutraceuticals

Many studies have shown the effectiveness of the nutrients in the following table. All are effective for prevention of migraine. (20) (21) (22)

Vitamins, Minerals, Supplements and Herbs

Butterbur (Petadolex)

Feverfew

Magnesium

Vitamin B2 (Riboflavin)

Coenzyme Q10

Ginger

Melatonin

Devices

The sTMS was shown to reduce frequency and severity of migraine attacks when patients followed the recommendation of using the device daily. The company that manufactured this device has filed for bankruptcy, so it is unknown about the availability of this device in the future. (23)

Nerivio is a device worn on the arm and works by descending pain modulation via the brainstem. It is both safe and effective. Having it demonstrated can be helpful in making sure everyone is on the same page and gets best results. (24)

The gammaCore device is well tolerated and can be used in the preventive treatment of migraine and chronic cluster headache. It is placed against the neck and activated to stimulate the vagus nerve. gammaCore is thought to reduce the release of glutamate in the brain during a migraine attack and also to disrupt the cortical spreading depression. (25)

Cefaly has been shown to effectively help treat and reduce episodic migraine attacks. (26)

Green light therapy has been shown to reduce the overall severity of migraine attacks. The Allay lamp is one form of green light therapy that uses the narrow band of green light to help reduce migraine symptoms. (27)

Devices	Brand Name
Vagus Nerve Stimulator	gammaCore
External Trigeminal Nerve Stimulator	Cefaly
Non-invasive neuromodulation device	Nerivio
Single-pulse transcranial magnetic stimulation	sTMS by eNeura
Narrow band green light therapy	Allay Lamp

Other Miscellaneous Preventive Treatments

A course of six sessions of full body acupuncture has been shown to be effective in the prevention of migraine. In 3-6 months, migraine attacks were halved for half of the people participating in the 100 person study. (28)

Biofeedback is “effective in reducing the frequency of migraines with clients using medication resulting in a more favorable outcome (70% experiencing at least a 50% reduction in headaches) than just medications alone (50% experience a 50% reduction)”. (29) Biofeedback can be learned through a trained professional or some apps that are on the market or will be soon.

Miscellaneous Treatments

Acupuncture

Biofeedback

Different Approaches to Preventive Therapy

While looking at all of the medications listed in the tables above can be overwhelming, headache specialists and other doctors interested in migraine can combine those and others not listed to tailor a preventive therapy for each individual patient. Each of the writers for Migraine Strong have different preventive therapies for migraine and they are all effective.

Eileen’s Therapy – Chronic Migraine, Migraine with Brainstem Aura

I have had migraine for most of my life and even spent 18 years with chronic, daily, intractable migraine. I have tried many of the migraine preventive medications listed above which provided very little help during that span of time. However, I eventually added diet combined with topiramate to break that long cycle in 2015. Over the course of the next few years, my migraine morphed and required other add-on therapies for better management of symptoms. We added memantine first which helped to reduce light, sound and scent sensitivity, the last of which was the biggest trigger for brainstem aura attacks.

When Aimovig was released, I added that to my overall preventive strategy and it helped for 14 months before sort of fizzling out. The other injectable CGRP meds, Emgality and Ajovy, both helped me somewhat. Unfortunately, I had abdominal pain with both of them. I discontinued those meds and eventually weaned off of Topamax after passing 11 kidney stones in a month. Prior to this kidney stone episode, I had passed a few others that were over quickly and were an acceptable trade-off for the relief I had taking Topamax.

Migraine Preventive Medication Strategy

Currently, I get Botox every 12 weeks and took Qulipta with great results for 6 months. Sadly, the manufacturers coupon expired and it became unaffordable. I also take magnesium glycinate, ginger and use the Allay Lamp. I follow a low carb diet, walk 2 miles 4-5 days a week and I am considered chronic but well managed.

Danielle’s Therapy – Episodic Migraine

I was put on Topamax by Dr. Young at Jefferson Headache Center in Philadelphia. Dr. Young was adamant that I start low and increase slowly. He told me that Topamax is often not started properly. So, not only do people have negative side effects from it, but they stop a medication that may have given them their life back.

I was told to start at 12.5 mg and increase by 12.5mg each week until I reached 75mg. He said getting to 75mg wasn’t a race and that if I need more than a week for any side effects to fade, I could wait until I was ready. Great advice!

I stayed on Topamax for almost a year. Unfortunately, it did not help my head. If it had helped, the side effects would have been worth it. Candesarten was added with the intention of transitioning off of Topamax. During that time I was considered chronic.

Current Plan

I am no longer on migraine preventive medications as my attacks are infrequent and respond well to my acute medications. Diet and lifestyle have been and continue to be important to minimizing my attacks. I am also being helped by being in midlife and have written all about the topic of migraine and menopause recently. I survived perimenopause and am enjoying better migraine control in menopause.

Jennifer’s Therapy – Vestibular Migraine

Jennifer uses a multi-strategy preventative treatment plan that combines medications & natural treatment options to manage her symptoms of vestibular migraine.

Preventative Treatment Medication

Nortriptyline 20mg – You can find details about my medication experience along with details about the strategies shared below in my article about my vestibular migraine treatment plan. I’d like to add although it’s mentioned above that anti-depressants are used to treat migraine in patients with comorbid depression and anxiety, that is not always the case. Amitriptyline is a well researched stand alone migraine preventative medication. Tricyclics such as nortriptyline & amitriptyline are often used as a primary preventative medication even for patients with no history of anxiety & depression. My doctor chose it for me because a known side effect of nortriptyline is weight gain. I weighted just 87lbs when I was diagnosed with vestibular migraine due to the daily dizziness & nausea I experienced while I waited for months for proper diagnosis & treatment. Using medication side effects to improve treatment is a smart strategy even when comorbidities are absent.

Natural preventative treatment strategies

The Heal Your Headache Diet – I chose the Heal Your Headache to remove common triggers. It took about a year for my hyper-responsive brain to calm down. Once that happened, I began to test foods to determine my personal food triggers. Today my symptoms are so controlled I have very few.

Movement – Moving helps your brain learn to compensate & recover from daily dizziness. My advice is to start slow. Walking, stationary bike, low impact and/or core & balance strengthening exercises are often a good place to start. Go slow and be gentle in your recovery.

Hydration – Hydrate, hydrate, hydrate! Your brain needs to be properly hydrated to recover. I am ALWAYS working on this.

Regulated Sleep – This is such an underrated vestibular migraine treatment strategy.

Engaging in intentional calm down activities – Engaging in activities that help you feel calm…on purpose can help soothe a hyper-responsive central nervous system. Grounding techniques can help your brain compensate & realize you are not actually moving when you feel like you are.

Supplements – Every supplement I take is for a very specific reason to help minimize and manage symptoms. I’ve discussed every supplement I take with my doctor before I take it and you should too.

Magnesium Glycinate– I take 2-3 capsules of Pure Encapsulations brand daily.
Magnesium Threonate– I take Pure Encapsulations brand 1-2 capsules per day.
Ginger– I take one Ginger or Turmeric capsule per day. I like both Gaia Herbs and Pure Encapsulations brands.
B Complex Plus– I use Pure Encapsulations brand and take one capsule per day.

Conclusion

I hope this guide and our personal treatment plans have shown that there are lots of different options out there to help us manage migraine. Chat with your doctor about options and join the Migraine Strong Private Facebook group to talk to others in the same boat.

References:

Your Practical Guide to Migraine Preventive Medications

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Your Practical Guide to Migraine Preventive Medications

Intent Of This Article