Migraine Prevention

Migraine prevention is a complicated topic. I explain to my patients that each person has a built-in threshold for having a migraine, based on their genetics. Because of this built-in difference, some people will only have migraine headaches under unusual circumstances. This might be someone who only has a migraine if there is stormy weather just prior to menstruation after having slept poorly the previous night. Someone with a lower threshold might get a migraine just from sleeping poorly the previous night. Still another person has migraines very, very frequently - and it can be difficult for him/her to identify or to avoid all of the potential triggers.

There are many kinds of triggers (see the list ) that include both external factors (environment) and internal factors (emotions). Some things can be controlled (like exposure to certain foods) and others cannot (such as low-pressure weather).

Preventative (or prophylactic) medications are generally felt to work by increasing the threshold for getting a migraine. Someone who has 2-3 migraines per month might have no migraines after starting a certain preventative medication. This is certainly a great, though uncommon, outcome. Another person might have migraines, on average, 15 out of every 30 days when not on a preventative medication. For this person, a reduction to 5 headache days for every 30, while on a preventative, is a considerable improvement. Preventatives also can have the effect of reducing the intensity of the migraines that do occur and making them easier to treat.

Medications:

Keep in mind that each person is different, with different underlying headache causes and slightly different biology. As a result, what works very well for one patient may not help at all for another. For this reason, using medications to try to prevent migraines is partly a process of trial and error. Preventative medications are usually tried for at least 4-6 weeks before determining whether they have been helpful or not.

There numerous medications used to prevent and reduce the intensity of migraines. Four of these are ranked as the best because they have excellent scientific data and a great track record for helping to control migraines. These are tricyclic antidepressants, Topamax (topiramate), beta-blockers, and Depakote (valproic acid). Let's discuss each of these medications in turn.

Before we go further, please note that medications have many potential side effects which I do not discuss here. In addition, advice here cannot replace the advice of your treating physician. Your physician will need to discuss which and whether to use a preventative medication and the many potential side effects.

Tricyclic antidepressants

Tricyclic antidepressants are an older class of antidepressant which have proven very helpful in treating sources of pain, including migraines. These medications create higher concentrations of serotonin (which is known to affect some migraine-related brain receptors) and noradrenaline around nerve terminals. I usually use amitriptyline - starting with 10mg at bedtime and slowly increasing by 10mg each week up to a dose of 100mg at bedtime. If a patient hasn't improved significantly by the time they are on 50mg, they are unlikely to benefit from further increases. Amitriptyline has the advantage of helping people to sleep if they also suffer from insomnia. Unfortunately, it can also cause a high heart rate, the feeling like your heart has 'skipped a beat'(palpitations), constipation, dry mouth, weight gain, urinary retention, blurred vision, daytime sedation, and other side effects. If a patient doesn't need help falling asleep, other tricyclics such as Pamelor (nortriptyline) or imipramine can be used at the same dosing as amitriptyline.

Topamax

Topamax (topiramate) was originally marketed as a medication to prevent seizures, and it is effective for this. In the headache world, though, it has become very popular because it both markedly reduces migraines and tends to lead to weight loss. Patients are typically started on 25mg at bedtime and can increase their dose (as needed and as tolerated) up to 100mg at bedtime. If a patient is particularly sensitive to the side effects, he/she can increase the dose more slowly or can be started on 15mg doses, increasing by 15mg each week. Side effects can include excessive weight loss, nausea, tingling in the mouth, tongue, arms or legs, and poor memory or concentration. Rarer but serious side effects include the development of kidney stones (about 1.5% of cases), metabolic acidosis, and rare cases of glaucoma. I have had a few patients discontinue the medication because they felt it made them depressed or exacerbated their asthma, though these side effects also are uncommon.

Beta-blockers

The two beta-blockers I tend to use are propranolol (because it is available in low doses, is cheap and effective) or Corgard (nadolol) (because it is easy to use and has fewer side effects). These medications are typically used to treat high blood pressure or elevated heart rate. Propranolol can be started at 10mg twice a day and titrated up to 20mg twice a day. If a patient requires further increases at this point, I will switch to longer-acting, higher dose propranolol such as Inderal LA (60mg, 80mg, 120mg, and 160mg doses available). Potential side effects of beta-blockers include exacerbation of asthma or diabetes, too low blood pressure or heart rate, fatigue, and depression. Corgard tends to have less associated fatigue and can be started at 20mg a day - with titration as high as 80-120mg per day.

Depakote

Depakote (valproic acid) is an older anti-seizure medication which is effective in reducing migraine frequency and intensity. I typically place patients on Depakote ER, since it can be taken once a day (usually at bedtime). Patients can be started on 250mg and gradually increased in dose as needed and as tolerated - typically up to about 1000mg. Depakote is known to cause birth defects (pregnancy category D) and so female patients must be infertile or have an effective means of birth control if they use Depakote. Other potential side effects include liver dysfunction and damage, weight gain, elevated blood ammonia levels, sedation, and anemia along with other blood product suppression. Given the side effect profile, Depakote is used much less often than other headache preventatives.

Other Medications

Many other medications have evidence supporting their use as migraine preventatives. In no particular order, here is a review of some of these less common options:

Other tricylic medications are probably effective for migraine prevention including Vivactyl (protripyline) and doxepin.

Evidence to support the use SSRIs (a special class of antidepressant) is poor- but can be justified if a patient is suffering from depression. Common options used include Prozac (fluoxetine), Celexa (citalopram), Lexapro (escitalopram), and Paxil (paroxetine).

There is evidence that Effexor (venflaxacine), which is another type of antidepressant called an SNRI, is helpful for migraine prevention. A similar drug (Cymbalta) may also be helpful. There is support for use of the antidepressant Nardil (phenylzine) in a class called MAOI.

Other anti-seizure medications that are probably helpful include: Neurontin (gabapentin), Lamictal (lamotrigine), and Zonegran (zonisamide).

Other beta-blockers in use from migraine prevention include atenolol, metoprolol, and timolol.

Calcium channel blockers may benefit migraine patients - the most commonly used are verapamil or diltiazem.

Cyproheptadine (Periactin, a non-selective antihistamine) has shown some benefit for migraine prevention.

Lisinopril (an ACE-inhibitor, generally used to treat high blood pressure) has at least one study supporting its use as a headache preventative. The same goes for the anti-hypertensive Atacand (candesartan, which is an angiotensin receptor blocker.)

Combination Therapy

If one prevention measure does not work sufficiently for migraine prevention, I will often add others. This includes the use of multiple migraine prevention medications, if needed. Sometimes the use of multiple low dose preventative medications is more effective, safer, and easier to tolerate, than a higher dose of a single medication.

Supplements

All of the following supplements have evidence to support their role in preventing migraine headaches. I typically recommend B2, Coenzyme Q10, and Magnesium to my patients.

Magnesium oxide (400mg per day)

Feverfew (Tanacetum parthenium, 100mg) or MIG-99 (feverfew extract, 625mg TID)

B2 (riboflavin, 400mg per day)

Coenzyme Q10 (100-150mg twice a day)

Butterbur (Petasites extract, 75mg twice a day)

Procedures

Trigger point injections - If a patient has chronic pain and tension of the shoulder or neck muscles, simple palpation of these muscles can elicit pain. In these cases, trigger point injections may be helpful. These involve the injection of an anesthetic agent combined with an anti-inflammatory medication. In our practice, we use a combination of lidocaine mixed in a 50:50 solution with Depomedrol (a steroid). Injections are most effective for migraine prevention if performed in a series (two times per week for 2-3 weeks) to reduce pain and inflammation in the muscle.

Occipital nerve blocks - The greater and lesser occipital nerves run from the back of the head (the superior nuchal line) toward the front of the head. These nerves can become compressed and irritated, giving rise to pain. Pain can often be elicited by pressing over these nerves at the back of the skull. Nerve blocks (using the same medications as for trigger point injections, see above) given 2 times a week for 2-3 weeks can greatly reduce the pain caused by these nerves, and therefore aid in migraine prevention. For more information about occipital nerve pain, click here.

Botox administration - Botox is a purified botulinum toxin that inhibits the nerve-to-muscle connection, leading to muscle relaxation. Studies are conflicting as to its efficacy for migraine prevention. We typically use it to treat muscle problems that are also associated with headaches (chronic muscle spasm and dystonias) or for headache prevention when a patient has failed to respond to many of the standard treatments. For more information about Botox for migraine prevention, click here.

Biofeedback/Neurofeedback

Biofeedback and neurofeedback may help some patients in their quest for migraine prevention. For more information, see this link.

Behaviors

Avoid any known or suspected triggers

Obtain regular and sufficient sleep

Consider treatment of persistent sleep disorders, excessive sleepiness, or fatigue.

Avoid caffeine if it is a trigger

Taper off caffeine altogether if it has been noted that sudden withdrawal is a trigger

Emotional Considerations

Avoid (to the degree possible) sudden rises and falls in the degree of stress or anxiety

Consider treatment of depression (professional advice, medications)

Consider treatment of anxiety (professional advice, medications)

See this link regarding menstrual migraine headaches for prevention and treatment of these special migraines.

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