Medications for Preventing Episodic Migraines

Aimovig, Ajovy, Toprol, and Other Options

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If you have episodic migraine headache—a subtype of migraine headache disorder defined by the International Classification of Headache Disorders (ICHD-3) as fewer than 15 headache days per month, with or without aura—prevention is key to managing your condition. Avoiding triggers, managing stress, and committing to other healthy lifestyle habits are important, but many with episodic migraines also need to take medications—prophylactic drugs that help prevent migraine attacks.

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Currently, only one class of drugs that was developed for the sole purpose of preventing migraine headaches is available. All others, so-called oral migraine prevention medications (OMPMs), primarily are used to treat other conditions but have been found useful as migraine prophylactics.

Finding what's most effective for your migraines can take time, and it's important to discuss all the options with your doctor.

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Calcitonin Gene-Related Peptide (CGRP) Antagonists

These prophylactic migraine medications are monoclonal antibodies, a type of biologic drug produced using living systems rather than being synthesized from chemicals. They work by blocking the docking site of a protein called calcitonin gene-related peptide (CGRP) or the CGRP itself, which plays a part in the transmission of pain released from trigeminal nerve fibers that supply sensation to areas of the face.

Five CGRP antagonist medications have been approved by the Food and Drug Administration (FDA) for preventing migraine: Aimovig (erenumab), Ajovy (fremanezumab-vfrm), Vyepti (eptinezumab-jjmr), Emgality (Galcanezumab-gnlm), and Nurtec ODT (rimegepant).

In May 2021, the FDA expanded approval for Nurtec ODT to include migraine prevention, making it the first and only migraine medication to both treat and prevent migraines.

Aimovig and Ajovy are injectable medications that you can inject into your thigh or abdomen yourself or have someone else inject into your upper arm. Aimovig comes as either a prefilled syringe or an autoinjector (spring-loaded syringe) to be used once a month. Ajovy is available as a prefilled syringe and is taken as a single injection once a month or three consecutive injections every three months.

Emgality is also taken as a single injection once a month. Vyepti works a little differently. It is administered by a healthcare professional once every three months intravenously (by IV), and the infusion generally takes 30 minutes.

Nurtec ODT is the only medication in this class that is taken in pill form. One 75 mg pill is taken every other day for prevention of migraine, but can also be taken after a migraine starts as long as you haven't already had a dose that day.

The side effects of this class of drugs are relatively mild.

Beta-Blockers

Drugs in this class are primarily used to treat high blood pressure (hypertension). It's thought that these drugs help keep migraine attacks at bay by preventing blood vessels from over-dilating and by calming the nervous system, thus reducing anxiety, according to the National Headache Foundation.

The beta-blockers found most effective for episodic migraine prevention are Toprol (metoprolol), Inderal XL (propranolol), and timolol. They're regarded as level A drugs for this purpose, meaning their effectiveness is proven. Two other beta-blockers, Tenormin (atenolol), and Corgard (nadolol), are level B OMPMs, meaning they're "probably effective."

Beta-blockers may not be a safe choice for people who have asthma, diabetes, symptomatic bradycardia (slow heart rate), or low blood pressure. For others, the drugs can have bothersome side effects including low mood, fatigue, and erectile dysfunction.

Anticonvulsants

Although the physiology of migraine headaches isn't completely understood, scientists believe some of the same structures and functions in the brain that are affected in epilepsy are also involved in migraines.

That's one reason certain medications for managing epileptic seizures are considered level A drugs for preventing migraines—specifically valproic acid (available as Depakote and others) and Topamax (topiramate).

Although they can be effective, these medications have the potential to cause side effects that are bothersome enough to cause people to stop taking them, including weight gain or weight loss, fatigue, dizziness, nausea, changes in taste, tremor, paresthesias, and hair loss.

Antidepressants

Amitriptyline is a tricyclic antidepressant that affects mood by blocking the reuptake of the brain chemicals serotonin and norepinephrine. It's this action that may make it an effective prophylactic migraine medication.

However, like other OMPMs, amitriptyline has uncomfortable side effects including nausea and vomiting, dry mouth, constipation, urine retention, weakness, sweating, changes in appetite or weight, and more. It also can cause nightmares and confusion. In addition, the drug can result in cardiovascular problems and shouldn't be taken by people with underlying heart disease.

A Word From Verywell

The toll of a day lost to debilitating pain and other symptoms from episodic migraine, such as nausea and vomiting, can be significant. The development of prophylactic migraine headache medications such as the CGRP antagonists should be a welcome relief for anyone who gets frequent migraines, especially those who have trouble tolerating OMPMs.

There are many options, so if one drug doesn't work for you, talk with your doctor about trying others until you find one that will, at the very least, decrease the number of days you find yourself down for the count with a migraine.

Chronic migraine is characterized by 15 or more headache days per month over the course of three months, with or without aura. If your episodes increase to this extent, be sure to tell your doctor as well.

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  1. Nurtec ODT (rimegepant). Full prescribing information. Updated May 2021.

  2. National Headache Foundation. Beta-blockers.

  3. Shahien R, Beiruti K. Preventive agents for migraine: Focus on the antiepileptic drugsJournal of Central Nervous System Disease. 2012 Jan;4(1):37-49. doi:10.4137/JCNSD.S9049

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