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
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.
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 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)
Cochrane reviewed two preventative therapies for the treatment of migraine:
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 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.
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.
- 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