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Headache: The Journal of Head and Face Pain

2013 American Headache Society

Published by John Wiley & Sons, Inc.
doi: 10.1111/head.12191

Headache Toolbox

Prevention of Migraine
When migraines become so frequent or cellaneous group. Choosing between these
severe that they interfere with work or usual groups could be based on whether an individual
activities, it is time to consider using preventive has other health concerns. For example, those
strategies. If acute medications are being used with depression would be helped on two fronts,
more than 2 days per week, this alone can lead headache and mood, by choosing an anti-
to more headaches, sometimes called rebound depressant. Those with higher blood pressure
or medication overuse headaches, and the only would choose the antihypertensive group, and if
way out of this quagmire is to start a preventive a patient has a history of seizures, some of the
strategy. anti-epileptic medications may help with their
Prevention is not a cure. It is highly likely that migraines.
migraines will continue to occur, and in fact a Blood Pressure Medications.These are old
preventive may be considered successful if the standbys in headache prevention because they
frequency, severity, and/or intensity of the help address any elevations in blood pressure,
headaches are cut in half. There is no preventive they are typically inexpensive, and beta-blockers
strategy known that does not have the potential can be effective in reducing anxiety, which is not
for side effects, but this must be balanced an uncommon problem in migraine patients. The
against the possible gain from feeling better, and most evidence favors the beta-blockers
being able to work, play, and generally function metoprolol, propranolol, and timolol, followed by
more normally without relying too much on atenolol and nadolol. Propranolol and timolol
ongoing acute medications. have US Food and Drug Administration (FDA)
In 2012, new guidelines were published by approval for migraine prevention; the others do
the American Headache Society outlining not. Should beta-blockers not be advised, for
recommendations for preventive migraine example in very athletic patients, or those with
medications based on evidence from published Raynauds (spasm of the arteries in the fingers
studies and clinical experience. The choice of with cold) or asthma, the angiotensin-converting
preventive medication needs to be a balance of enzyme inhibitor lisinopril, or the angiotensin
effectiveness and whether it helps with other receptor blocker candesartan, may be useful.
problems a migraine sufferer may have, versus For those who have heard that calcium channel
any potential side effects. blockers, such as verapamil, may help prevent
Dividing up preventive medications into migraine, the most recent guidelines did not find
broad categories may be helpful in deciding strong evidence to support their effectiveness.
which strategy is appropriate. For this toolbox, Anti-Seizure Medications.This group of
we will start with the prevention of episodic medications can be equally as effective as beta-
migraines, that is, attacks of migraine in which blockers, depending on which ones are chosen.
the total number of headache days per month is Divalproex sodium and sodium valproate (often
less than 15. called Depakote) is a long-standing and effective
Five categories to be considered for preven- preventive agent. Generally, it is well tolerated
ting episodic migraines are the blood pressure too, but can be associated with weight gain, can
group, the anti-seizure group, the antidepressant affect the ovaries, can cause birth defects, and
group, the natural supplement group, and a mis- should be avoided by those with liver disease.


Topiramate is another effective preventive headache. Onabot is administered using 31

medication. While it can result in tingling, word small injections in the head and neck in defined
finding problems, and memory issues, its most locations. Although often effective, it must be
beloved side effect is the potential for weight administered every 90 days by an individual
loss. Both valproate and topiramate are trained in the migraine injection protocol. It is
FDA-approved for migraine prevention. Other expensive, and many insurance companies
common medications for prevention, such as require that a patient try other preventive agents
gabapentin and lamotrigine, lacked sufficient first, even though there are no other FDA-
evidence for being effective. approved medications for chronic migraine.
Antidepressant Medications.Amitrip- Onabot is well tolerated and does not result in
tyline is an old, inexpensive medication and problems with thinking, mood, or weight gain,
effectively prevents episodic migraine. While it can which can be issues with other preventives.
help with sleep and mood, it can result in weight Triptans can also be used preventively in
gain, sedation, and dry mouth. A newer anti- certain well-defined circumstances. Although
depressant that made it to the preventive list is overuse of these migraine-specific medications
venlafaxine, which helps with mood and does not can increase headache frequency, when used as
result in weight gain. It is usually taken in the mini prevention or for short periods of time
morning and can be energizing, so it does not when migraines can be predicted, frovatriptan
help people fall asleep. Selective serotonin and naratriptan can be effective. For example,
reuptake inhibitors, such as fluoxetine (Prozac), women may use them for the week just before
sertraline (Zoloft), and paroxetine (Paxil) work and just after the start of menses, although they
well for depression and anxiety, but lack strong are not FDA-approved for this purpose.
evidence supporting effectiveness as migraine
Nutritional Supplements, Vitamins, and Preventing migraines, decreasing their
Minerals.The supplement group is usually well frequency, intensity, or severity, or even making
tolerated by most people, although the effective- them more responsive to acute medications are
ness may not match stronger prescription important goals for every migraine sufferer.
counterparts. Petasites (butterbur) was found to Ideally, the choice of preventive strategy should
be effective as a preventive. Riboflavin, be matched to the individual patient. Many times
magnesium, and MIG-99 (feverfew) are probably preventive medications can help treat another
effective, and CoQ10 is possibly effective. problem, such as high blood pressure, depres-
sion, anxiety, or trouble sleeping. A preventive
MISCELLANEOUS PREVENTIVE STRATEGIES strategy is best formulated with a team approach
There is only one FDA-approved medication involving the patient and caregiver, balancing
for preventing chronic migraine, defined as effectiveness, side effects, and potential non-
headache at least 15 days per month at least 4 migraine benefits.
hours per day. OnabotulinumtoxinA (commonly
called onabot or Botox) was approved by the Deborah Tepper, MD
FDA in October 2010 for those with chronic Cleveland Clinic, Cleveland,
migraine, also referred to as chronic daily OH, USA

To find more resources, please visit the American Migraine Foundation