Medications to Prevent Episodic Migraines

Guidelines from the AHS/AAN

How Can You Prevent a Migraine with Medication?. Brand New Images/Collection Vision/Getty Images

Maintaining a headache diary is something many of us migraineurs do in order to identify our migraine triggers. By meticulously keeping track of and avoiding our triggers, we hope to avert a debilitating migraine attack. Yet, let's be frank, despite trigger avoidance, many migraineurs still require a daily medication to prevent these dreaded headaches.

What is a Migraine Preventive Medication?

Preventive medications are taken daily to reduce the number, severity, and duration of migraine attacks, as well as minimize the disability brought on by frequent headaches. They are commonly used for those who suffer from chronic migraines, but can also be used for episodic migraineurs.

Examples of potential indications (other than chronic migraine) for preventive medications include: a contraindication to abortive therapies and/or an impaired quality of life or daily functioning. Rare forms of migraine like hemiplegic migraine or basilar migraine may also be an indication for a preventive medication.

The American Headache Society (AHS) and American Academy of Neurology (AAN) established guidelines on medications they recommend for the prevention of episodic migraine -- migraines that occurless then 15 days per month. Still, many of these same medications are used as prevention in those who suffer from chronic migraines.

Typical preventive migraine therapies.

  • Antihypertensives (blood pressure lowering agents)
  • Antidepressants
  • Anticonvulsants
  • Petasites (Butterbur)

Blood Pressure Lowering Medications to Prevent Migraines

Several types of medications are used to prevent migraine attacks. Blood pressure lowering agents, especially beta-blockers, are classically used. The AHS/AAN determined that metoprolol, propranolol, and timolol are level A drugs. This means they are considered "effective" for migraine prevention, while atenolol is a Level B drug or "probably effective."

Beta-blockers should be used with caution in those with asthma and diabetes and are relatively contraindicated in those with symptomatic bradycardia (low heart rate). Other side effects of beta blockers include low mood, fatigue, and erectile dysfunction.

Other blood pressure medications like verapamil, a calcium-channel blocker, are also sometimes used to prevent migraines, although the scientific evidence behind it is not as strong as that of beta-blockers. The AHS/AAN 2012 guidelines listed verapamil as a "U" drug, meaning there is "insufficient data to support or refute use for migraine prophylaxis.” The antihypertensives lisinopril and candesartan (known as ACE inhibitors) were categorized as level C drugs by the AHS/AAN, which means they are "possibly effective" based on one single study.

Antidepressants to Prevent Episodic Migraines

Antidepressants, especially amitriptyline and venlafaxine, are considered Level B drugs ("probably effective") for migraine prevention. Venlafaxine (Effexor) is a selective serotonin-norepinephrine reuptake inhibitor. Amitriptyline (Elavil)  is the most common tricyclic antidepressant that works by blocking the reuptake of two neurotransmitters in the brain, serotonin and norepinephrine.  It is a sedating medication and typically taken at bedtime.

Amitriptyline also blocks acetylcholine receptors and histamine receptors in the brain, causing potential anticholinergic side effects like dry mouth, constipation, and urinary retention. It also can cause weight gain and confusion. Finally, amitriptyline can have very serious side effects like cardiac conduction abnormalities, so should be avoided in those with underlyng heart disease.

Anticonvulsants to Prevent Episodic Migraines

In terms of anticonvulsants, the American Academy of Neurology concluded that the valproate products, divalproex sodium, and sodium valproate, as well as topiramate (topamax) are effective (Level A drugs) in preventing migraines. Side effects of topiramate include

  • weight loss
  • fatigue
  • dizziness
  •  paresthesias
  • cognitive dysfunction
  • taste alteration.

Side effects of valproate medications include: weight gain, nausea, tremor, and hair loss.

Butterbur and Other Medications to Prevent Episodic Migraine

Petasites (butterbur) is another Level A drug effective for migraine prevention. This is an herbal or alternative medication that is taken twice daily. The main side effect is mild GI upset, especially burping.

Other level B drugs or drugs that are "probably effective" for migraine prevention, as noted by the American Headache Society and American Academy of Neurology include:

The Bottom Line

Preventive medications are sometimes indicated to reduce the number, severity, duration, and disability associated with migraines. According to the experts, certain beta-blockers (metoprolol, timolol, propanolol),  anticonvulsants (valproate products, topiramate), and the herbal supplement butterbur have been established as Level A or "effective" as preventive medications for episodic migraines.

If you find that your migraines are negatively impacting your daily functioning or quality of life, talk with your doctor about the possible benefits and risks of starting a migraine preventive medication -- it may be something you need temporarily until your can determine your migraine trigger or find an alternative way to cope. 

DISCLAIMER: The information in this site is for educational purposes only. It should not be used as a substitute for personal care by a licensed physician. Please see your doctor for diagnosis and treatment of any concerning symptoms or medical condition.

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