several migraine preventive medications on a white surface
Chronic Migraine,  Episodic Migraine,  Medication,  Migraine,  Vestibular Migraine

Migraine Preventive Medications: Comprehensive Guide

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 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. 

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 likelihood that the patient 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. Most of the VM members of Migraine Strong have found relief with starting the Heal Your Headache diet.

flowchart for treating vestibular migraine

Dr. Shin Beh recently 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 I 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 and your dose might be dependent on other variables if they don’t match up.

Beta Blockers

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)

Beta BlockersBrand Name
PropanololGeneric
NadololCorgard, Generic
AtenololTenormin, Generic
MetroprololToprol XR, Lopressor, Generic
TimololBetim, Generic

Injections 

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. 

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.

InjectionsBrand Name
OnabotulinumtoxinABotox
ErenumabAimovig
FremanezumabAjovy
GalcanzumabEmgality
eptinezumab-jjmrVyepti
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
CandesartenAtacand, Generic
LisinoprilZestril, Prinvil, Generic

Calcium Channel Antagonists/Blockers

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 AntagonistsBrand Name
Flunarazine (not available in the US)Sibelium
VerapamilVerelan PM, Verelan DR, Calan, CalanSR, Generic

Antidepressant Medications

“Migraine and chronic TTH (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 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 “their 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.

The tricyclic antidepressants have shown to be effective in treating migraine and chronic tension-type headache. They can often help with sleep as well. Sometimes amitryptiline has a side effect profile that patients find unfavorable, so nortriptyline is often prescribed instead. 

Tricyclic AntidepressantsBrand Name
AmitriptylineElavil
NortriptylinePamelor
Protriptyline
DoxepinSinequan
Selective Serontonin Reuptake Inhibitor (SSRI)Brand Name
CitalopramCelexa
EscitalopramLexapro
FluoxetineProzac
ParoxetinePaxil, Pexeva
SertralineZoloft
Selective Serotonin/Norepinephrine Reuptake Inhibitor (SNRI)Brand Name
VenlafaxineEffexor
DuloxetineCymbalta
DesfenlafaxinePristiq

Anticonvulsants

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. 

AnticonvulsantsBrand Name
Topiramate, Topiramate XRTopamax, Topamax XR, Generic
Sodium ValproateDepakote, Epilim, Epilim Chrono, Episenta, Generic
GabapentinNeurontin
PregabalinLyrica
ZonisamideZonegran
LevetiracetamKeppra
LamotrigineLamictal

Muscle Relaxants

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)

Muscle RelaxantsBrand Name
CyclobenzaprineFlexeril
TizanidineZanaflex
BaclofenLioresal

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 TriptansBrand Name
Naproxen/Naproxen SodiumNaprosyn/Aleve
FrovatriptanFrova, Generic
NaratriptanAmerge
SumatriptanImitrex, Generic
ZolmitriptanZomig

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) And Memantine also reduces the frequency and severity of migraine and is effective when added on to other therapies. (19)

Miscellaneous MedicationsBrand Name
AcetazolamideDiamox
SpironolactoneAldactone
MemantineNamenda

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. (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)

DevicesBrand Name
Vagus Nerve StimulatorgammaCore
External Trigeminal Nerve StimulatorCefaly
Non-invasive neuromodulation deviceNerivio
Single-pulse transcranial magnetic stimulationsTMS by eNeura
Narrow band green light therapyAllay 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. I discontinued that and eventually weaned off of Topamax after passing nine kidney stones in a month. Prior to this kidney stone episode, I have passed a few others that were over quickly and were an acceptable trade-off for the relief I had taking Topamax. I added acetazolamide to take specifically for when barometric pressure changes were in effect. I use that preemptively and not daily.

Migraine Preventive Medication Strategy

Currently, I take memantine, Aimovig (recently added back when attacks increased after discontinuing topiramate) melatonin, acetazolamide (preemptively), magnesium glycinate, ginger and the Allay Lamp. I also follow a low carb diet 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.

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.

Jennifer’s Therapy – Vestibular Migraine

I use a variety of preventives including diet, supplements, exercise and medication.

My Preventative Treatment Plan

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.

The Heal Your Headache Diet – I chose the Heal Your Headache to help end my daily dizziness. I still follow a personalized version of it today.

Movement – Moving helps your brain learn to compensate. My advice is to chose walking, stationary bike, low impact and/or core & balance strengthening exercise. 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.

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

Engage in intentional calm down activities – Engage in activities that help you feel calm…on purpose!

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.

Marina’s Therapy – Chronic Migraine

I’ve had migraine since I was 13, however it became chronic when I was pregnant and gave birth to my children. I was experiencing daily migraine attacks which were complicated by rebound headaches.

Currently, I’m on multiple preventive medications in addition to Botox and Emgality. I also get occasional nerve blocks on an as needed basis and avoid personal food triggers like corn and bananas. I take ginger supplements to prevent and abort attacks.

Migraine is a spectrum disorder. Although some people can control it with one preventive medication, some of us require multiple to be able to live our lives to the fullest.

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:

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4640499/
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5990571/
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4640499/
  4. https://www.medscape.com/viewarticle/804034_14
  5. https://www.medscape.com/viewarticle/804034_14
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5990571/
  7. https://www.neurologyadvisor.com/conference-highlights/aan-2019-conference/ace-inhibitors-arbs-may-be-effective-migraine-prophylactic-treatments/
  8. https://www.medscape.com/viewarticle/804034_14
  9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6493799/
  10. https://www.practicalpainmanagement.com/patient/conditions/headache/6-medications-can-make-migraine-worse
  11. https://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825
  12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6493799/
  13. https://jnnp.bmj.com/content/76/12/1730
  14. https://www.medscape.com/viewarticle/804034_14
  15. https://www.nyheadache.com/blog/muscle-relaxants-for-migraines/
  16. https://www.neurologytimes.com/headache-and-migraine/treating-menstrual-migraines
  17. https://www.nyheadache.com/blog/migraine-drugs-a-to-z-acetazolamide/
  18. https://pubmed.ncbi.nlm.nih.gov/29913681/
  19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5603889/
  20. https://www.medscape.com/viewarticle/804034_14
  21. https://americanheadachesociety.org/wp-content/uploads/2018/05/Alan_Rapoport_-_Migraine_Prevention_Medications.pdf
  22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4640499/
  23. https://www.migrainetrust.org/living-with-migraine/treatments/transcranial-magnetic-stimulation/
  24. https://www.neurologylive.com/clinical-focus/experts-weigh-in-on-early-clinical-experience-with-nerivio-migra-in-acute-migraine
  25. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970666/
  26. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5440493/
  27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939697/
  28. https://www.cochrane.org/CD001218/SYMPT_acupuncture-preventing-migraine-attacks
  29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2826281/
Migraine Preventive Medications: Comprehensive Guide

I began having migraine attacks when I was a teenager, but was never properly diagnosed until I was an adult. This began 18 years where I was chronic and mostly intractable, resulting in a migrainous stroke in the summer of 2014. By implementing the protocols from the Heal Your Headache book by Dr. David Buchholz and the Migraine Strong Treatment Pie, I have been able to reduce my migraine frequency to episodic and maintain that since 2015. The end result of continuing to practice these tools is being able to actively participate in my life as a wife, mother, family member and friend. My goal as a migraine advocate, educator, and wellness coach is to help others gain more control over migraine. Let us know how we can help.

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