Contents
Preventative (prophylactic) migraine treatments
Part 2 looks at prophylactic or preventative migraine treatments. If you missed part 1) for Evidence-Based Acute Medications click here. Preventive treatments are used for migraine patients with a high number of days per month with migraine. Chronic migraine patients are commonly defined as those who experience migraine 15 days or more per month. In these cases, acute treatments can be easily overused and preventative treatments which are designed for daily use are often helpful to reduce the frequency and severity of attacks.
There are different types of preventative migraine treatments available. Many were developed for other purposes but have been found to be helpful for migraineurs.
Common preventative medicinal treatments include anticonvulsants, antidepressants, and beta-blockers.
Anticonvulsants for migraine
Anticonvulsants are anti-seizure medications. Their mode of action in migraine is not exactly clear. They are thought to reduce the capacity of the nerves to transmit pain signals to the brain.
In its study on anticonvulsants in 2013, Cochrane research found:
Anticonvulsants appear to be both effective in reducing migraine frequency and reasonably well tolerated. There is noticeable variation among individual agents, but there are insufficient data to know whether this is due to chance or variation in true efficacy. Acetazolamide, clonazepam, lamotrigine and vigabatrin were not superior to placebo (one trial each). Relatively few robust trials are available for agents other than sodium valproate/divalproex sodium and topiramate; gabapentin in particular needs further evaluation. Trials designed with sufficient power to compare different drugs are also necessary.1
In other words, anticonvulsants have relatively few side effects and appear to work quite well for migraineurs. The treatments which performed the best in the most scientifically robust studies were:
- Valproate/ divalproex sodium
- Topiramate
Topiramate
The Cochrane Collaboration reviewed 17 studies published up until Jan 2013. Compared to a placebo (i.e. a sugar pill) Topiramate reduced the frequency of migraine headaches by approx 1.2 per month from 9 studies with 1737 participants.(1)
There were another 9 studies with 1190 participants which showed people were also about twice as likely to reduce the number of migraine headaches by 50% or more with Topiramate than with placebo.(1)
Side effects were common but generally mild. Topiramate can cause birth defects so should be used with caution for women of childbearing age.
Valproate
10 studies were reviewed up to Jan 2013. Versus placebo, Valproate reduced the frequency of migraine headaches by approximately 4 per month from 2 studies with 63 participants. Patients were also more than twice as likely to reduce the number of their migraine headaches by 50% or more with Valproate than placebo from 5 studies with 576 participants.(2)
As with Topiramate, side effects for Valproate were common but generally mild. Valproate can cause birth defects so should be used with caution for women of childbearing age.
Given the research, both Topiramate and Valproate appear to be strong candidates to discuss with your doctor if you are considering preventative options for chronic migraine.
Antidepressants for migraine
Antidepressants alter your levels of serotonin, a brain chemical that regulates mood which is thought to be involved in the genesis of migraine pain.
Selective serotonin re-uptake inhibitors (SSRIs) are a type of antidepressant for migraine prevention. They block the passage of the neurotransmitter serotonin in the brain cells. SSRIs are typically used to treat depression but have also been tested for their potential benefit in preventing headaches.
Cochrane reviewed 13 trials with 636 participants. Only a few were of high quality and they were small and short in duration. Cochrane concluded that the “results suggested that SSRIs are no better than placebo for preventing migraine or tension-type headaches.” (3)
Other types of antidepressants for migraine had not been researched by Cochrane.
Beta Blockers
Beta-blockers are a class of drugs that block the effects of adrenaline-like substances produced by the body. It is not fully understood how beta blockers help prevent migraine headaches. It is thought that by decreasing production of these substances, the migraine condition improves. The most common beta-blocker for migraine is propranolol.
Propranolol is also one of the most commonly prescribed drugs for the prevention of migraine according to Cochrane.(4)
In 2004, 58 trials were reviewed by Cochrane that confirmed that Propranolol reduced migraine frequency significantly more than a placebo. However, conclusions could not be drawn about the efficacy or effectiveness of Propranolol due to the small sample size of the participants involved in trials.(4)
Essentially, all that can be scientifically claimed with propranolol is that it helps more than a placebo.(4)
Preventative Therapies
Cochrane reviewed two preventative therapies for the treatment of migraine:
- Acupuncture
- Feverfew
Acupuncture
22 trials investigated acupuncture in treating migraine headache.
6 trials looked at adding acupuncture to an existing treatment regime. Findings showed those who had acupuncture had fewer headaches.(5)
14 trials compared true acupuncture placebo or fake acupuncture treatments where needles were inserted superficially and did not penetrate the skin or at incorrect points. In these trials, both groups had fewer headaches than before treatment, but there was no difference between the effects of the two treatments.(5)
In 4 trials where acupuncture was compared to a proven medicinal treatment, participants receiving acupuncture tended to report more improvement and fewer side effects.(5)
Overall “the studies suggest that migraine patients benefit from acupuncture, although the correct placement of needles seems to be less relevant than is usually thought by acupuncturists.”(5)
I’ve had acupuncture. It didn’t have any noticeable effect on my migraine condition. But it was relaxing and calming. My hypothesis is that taking an hour to relax on a regular basis for a migraine weary individual is probably doing a world of good. I suspect the same could be said for other activities that help individuals relax, unwind and promote calmness i.e. like yoga, meditation, and relaxation etc.
FeverFew
Feverfew is a herbal remedy that is commonly suggested to migraineurs as a natural option. Cochrane reviewed 5 trials which assessed the efficacy of feverfew taken orally compared to placebo. Below are their key findings:
“Results from these trials were mixed and did not convincingly establish that feverfew is more effective than placebo for preventing migraine. No major side effects were associated with feverfew in the included studies. Further large and rigorously conducted trials are needed.”(6)
A clear statement that there is inconclusive scientific evidence in regards to Feverfew.
Opinion
If this has been half as interesting for you as it has for me researching and writing then you’ve learned a lot, gained a few options and hope for the future.
If I was chronic migraine patient starting again. I would first rule out medication overuse headache, then I would discuss the preventatives Valporate or Topiramate with my doctor.
I would also consider introducing other nonmedicinal approaches once I had settled into the new treatment. There are many options to consider.
For example, I’ve recently started using Vitamin B2 (Riboflavin) again at 200mg per day oral dose with some success. It is just my own results from my migraine diary which has shown to me that it helps increases my migraine threshold. I can see the evidence when I look back in my diary. Cochrane doesn’t yet offer any scientific reviews for Vitamin B2.
Remember, treatment is not just about taking a tablet and but instead developing a migraine management plan which will be unique for each individual. It will likely involve lifestyle adjustments, medications, complementary therapies, keeping a migraine diary and working in partnership with your doctor. And the most important person on your medical team is you.
Let me know in the comments your migraine treatment secrets or discoveries you’ve found.
Article References
- Linde M, Mulleners WM, Chronicle EP, McCrory DC. Topiramate for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010610. DOI: 10.1002/14651858.CD010610
- Linde M, Mulleners WM, Chronicle EP, McCrory DC. Valproate (valproic acid or sodium valproate or a combination of the two) for the prophylaxis of episodic migraine in adults. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010611. DOI: 10.1002/14651858.CD010611
- Moja L, Cusi C, Sterzi R, Canepari C. Selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headaches. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD002919. DOI: 10.1002/14651858.CD002919.pub2
- Linde K, Rossnagel K. Propranolol for migraine prophylaxis. Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD003225. DOI: 10.1002/14651858.CD003225.pub2
- Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD001218. DOI: 10.1002/14651858.CD001218.pub2
- Pittler MH, Ernst E. Feverfew for preventing migraine. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002286. DOI: 10.1002/14651858.CD002286.pub2
I’ve tried all of these, including your B2 dosage. I only found Valproate and Propranolol to help me. I also would agree that Valproate only provides a minor improvement. I think both of these reduced their effectiveness over time. I’ve tried acupuncture for migraine and other issues. It hasn’t had any effect for anything for me. I suspect your comment about the time to relax is the biggest real benefit of acupuncture.
I have found propanolol to work really well for me. Its interesting that the study doesn’t reveal much more info about it. I agree with you that it would be great if more studies would be done. It is such hard work to try drug by drug until you finally find one that works and I really think that GPs just don’t know enough about migraines. Thanks for this info!But i do find that propanolol makes me a bit tired and lethargic and has contributed to weight gain. But if i reduce the dose my migraines come back. so i am trading off the lethargy for mostly headache free!
Over the years I’ve tried all of these. Migril is the only thing that has ever worked for an acute migraine. That has been unavailable for a couple of years now. Indeed no ergotamine is available here in England, even to compounding pharmacies.
Painkillers, at the dosage advised on the box, have never touched the pain. Coffee alone sometimes works for a mild attack. Recent medical advice is to take a whole gram of an ibuprofen/paracetamol/caffeine combo at the first sign of attack, and this too sometimes works. Sometimes it does nothing. The danger is that tolerance for all three is likely to result so I vary it with pure aspirin or sometimes (rarely) Solpadeine (codeine and paracetamol); or else just wait it out. However the latter most often results in the attack just continuing to grow over a number of days.
There’s no doubt exercise, hydration, vitamins B2 and D and diet help to some extent. However, acupuncture, prophylactics, feverfew, light mask, cold/hot showers, calcium channel blockers, beta blockers, antidepressants…no.
This page refers to preventative migraine treatments. For acute migraine attacks, people respond very individually to different treatments. One thing that is worth trying is ginger.
Ginger was shown in a clinically study to be just as effective as Sumatriptan but one thousandth the cost. See the study results here http://nutritionfacts.org/video/ginger-for-migraines/
I’ve put my email in already, now I feel like if I’m ever to get the results I’m signing up for things I don’t want, and probably already did. I went back after 5 minutes and it told me to redirect – which took me to a new quiz. Now where are my answers? That’s all I want, no trouble, but not to waste my time taking a quiz that most of the answers didn’t apply or there should have been a button for more than one, or pick all – so my answers are all screwy anyway. I’d still like to see what I put and what "it’ thinks. Thank you Nikki Krug.
Hi Nicole, details to access your score and answers have been emailed to you.
I am now 67 years old and have had migraines from the age of 8 years old. I have tried every drug on the market, plus a gluten free diet, fever few, magnesium, Vitamin B and ginger. I then had injections into the back of my head that supposedly would stop them for three months, but they didn’t work at all.The only treatments that have had any long term relief are acupuncture (which halved the number from 12 a month to 6 a month) and Magnetic treatment, which worked wonderfully but was so expensive that i could no longer afford it. I now take Naratriptan when one starts, which works but taken too often can cause rebound migraine. I have now decided to try Daith Piercing as I would like to reduce them further still. I live in hope of a cure being found as most of my life has been spent trying to avoid a migraine.
Hi Mary, sorry to hear about your lack of progress. The good news is that there are many, many more treatments, strategies, therapies, devices, injections or approaches available for prevention than listed above. This list only details the thoroughly researched items. Unfortunately there are very few proven treatments with millions of dollars of research behind them but there are many options, doses and combinations worth considering. Good luck with the daith piercing. You might like to try a non permanent stud instead of a piercing to minimize any risks of an unwanted response.
Do you have any comments on the use of Calcium Channel blockers as a preventive measure?
Hi Ann, migraine has many “borrowed” treatments like this from other disease states. Calcium channels blockers are drugs used to decrease blood pressure in people with hypertension but evidence has demonstrated that it can also be effective for people with migraine. Personally, it wouldn’t be my first choice unless I had hypertension or if I had failed other preventive treatments due to lack of efficacy or side effects etc. It is certainly worth trying if everything up until now has failed and you don’t have any contraindications. I hope that helps.
I am 47 years old and have had miagraine since 13 years old. I got the daith piercing, and it was such a relief , no miagraine first 2 months. Felt so nice and such a relief. Only to dissapoint . It seems they are coming back now and lasting even longer. Ive had 3 bad ones in last month ina half .. lasting 3 or 4 days compared to 1 or 2 . Im just so tired of hurting . Medicines doesnt help is there anything else i can try ?
Hi Tonja, there are lots and lots of options. The Migraine World Summit, for example, has a premium directory that lists over 200 treatments for migraine. The other factors that are important to consider is the dosage, the timing of treatment and the format (i.e. oral pill, nasal, suppository etc.) There are also combinations which can create a synergistic effect, but make sure you are working with your doctor to ensure they supervise any combinations and your medications specifically.
Hi I suffered migraines for many years, but as I got older they seemed to decrease. During my early sixties, they bagan as, Silent Migraines ‘. I was getting five or six a week and couldn’t see a thing. Having to rush out of shops and sit in the car with a coat over my head. Then I read that older people lose an enzyme called,’ CQ10’and several studies have shown improvement. I tried it with a combination of that and Magnesium. It worked. I’m not completely clear but instead of five a week, it’s five a year. Try 200 mg. Good luck
Great to hear about your positive results Sally, these have shown to be helpful for people. They are not a cure but they can help some people significantly. I’m very glad they have helped you!