Migraine Prevention Medications

There are different types of medications and separate drug classes in the toolbox for migraine treatment. Developing a customized therapeutic approach is imperative.

Other factors must be taken into consideration when these medications are considered. If someone has high blood pressure, diabetes, asthma or other medical problems, different therapeutic options are available. Finding the right medicine can be a complicated process that requires experience and knowledge about the potential side effects.

Migraineurs (a word use to describe patients who experience migraine headaches) are justifiably averse to getting migraine attacks. These attacks can be downright debilitating and most people who experience migraine headaches want to avoid them at all cost.

When is a good time to consider being on migraine prevention?

If someone is experiencing more than 4 or more migraine headaches per month, the American Headache Society recommends treatment with a preventative medicine.

A preventative medicine is a medicine one takes every day to make the headaches less frequent and less severe. The medicine is taken every day even if the patient doesn’t have a headache.

This decision must still be discussed with a physician after both the patient and the doctor have a discussion about the goals of the treatment, the time needed for treatment to work, the expectation of the outcomes, and the potential risks and side effects.

One of the reasons preventative medication is used is because sometimes a cycle of pain can start where headaches seem to make more headaches. Patients can use over the counter or “abortive medications” (medicines to get rid of the headache) much more frequently. This can lead to a medication overuse headache; a situation that arises when the body builds a tolerance to medicine and more of the medicine can create a vicious cycle of headache, medication withdrawal and more headache. More on this topic soon.

The goal of preventative medication is:

  • -Reducing the headache frequency, severity and duration of attacks.
  • -Improving the responsiveness of acute abortive medications when they are necessary
  • -Decreasing the overall level of disability from the headaches
  • -Reducing the cost of using migraine abortive therapies
  • -Decreasing the use of acute migraine medications which can lead to migraine overuse headaches.

What are some of the pharmacologic and nonpharmacologic treatments of migraine?

Beta Blockers: Medicines such as Propranolol, Atenolol, Metoprolol, Nadolol, and Timolol were initially developed for angina and cardiac arrhythmias. We do not understand exactly how this medication works but it is effective in migraine prevention and can be helpful with patients who have migraines and high blood pressure.

Neuromodulators: Medicines such as Topiramate (brand name Topamax), Gabapentin (Neurontin) and sodium valproate (Depakote) have also been used as first line treatments for migraine prevention. These medications were originally created as anticonvulsants for seizures but have been studied in migraine prevention. Each medication has as different side effect profile and should be discussed thoroughly with the treating doctor. They are featured in the preventative headache medication list.

Antidepressants: The old antidepressants, that is, the class of medicines in the tricyclic antidepressant class are a first line treatment in migraine prevention. When these medications are prescribed, it does not mean that a patient has depression. Examples of this medication are Amitriptyline, Nortriptyline, and Imipramine. For migraine prevention lower doses of this medicine are typically prescribed than have been used for depression in the past. This can reduce many of the side effects and often people who have migraine and trouble sleeping may benefit from this medication.


Calcium Channel Blockers: Flunarizine and Verapamil are both in the class of calcium channel antagonists. These medications are thought to help prevent migraine by mechanisms that are still poorly understood. Verapamil can especially be helpful with treatment of prolonged aura.

Serotonin (5HT) Agonists: Methysergide (Deseril) and Pizotofen are potent preventative migraine medications. They however are not used as often as they tend to have severe side effects.

CGRP Antagonists: This novel medicine (new medicine with a new way of working) was recently released and approved by the FDA for migraine treatment. It targets CGRP receptors specifically in the body and is thought to reduce the amount of the pain producing molecule of this antibody. The medicine is used for patients with frequent headaches. It is currently available as Aimovig. Taken as a once monthly shot, this medicine has very few side effects and helps to prevent migraine attacks.

Botulinum Type A toxin (Botox): This treatment has been used to treat chronic migraines, that is (headaches that occur for 15 days a month or more). It is injected into specific sites in the forehead, the sides of the head, the back of the head and the top of the neck. It can be very effective in reducing both the number of headaches per month and the severity of the headaches. It can be used in conjunction with many other medications.

Other Nonpharmacologic Therapies

Acupuncture: This treatment involves inserting very small sterile needles into the skin at meridian points along the body. It can be effective in staving off migraines attacks. It may also have other beneficial effects including reducing stress, helping with sleep, and reducing nausea.

Occipital Nerve Block Injection: Occipital neve blocks targets the territory around the back of the head where the nerves from the base of the neck project up into the base of the skull and the back of the head. A steroid (a potent anti-inflammatory medicine) and a medicine such as lidocaine or bupivacaine (an anesthetic or numbing medicine) is used to try to disrupt painful signals that occur in a migraine headache. This numbing and interrupting of the pain can cause significant respite for migraineurs. This can often stop pain enough to clear a migraine.


Vitamin and Mineral Supplementation: Vitamin B2, Magnesium, and Feverfew are evidence based (demonstrated benefit for migraine treatment) supplements used to treat chronic migraines. These supplements are used to try to reduce the headache frequency and severity. There are different formulations of the supplements and they should be discussed with a physician.

Occipital Nerve Block Implant: This is a surgical operation where a stimulator is placed in the base of the skull. The electrical signals aim to “overload” the pain pathway, so the pain signaling is stopped.

This procedure is reserved for very refractory headaches, meaning those headaches that don’t respond to any other treatment.

It is important to note that all the information presented here is for general information. Concerns, issues and specific treatments need to be discussed meticulously with your doctor or neurologist before proceeding with ANY treatment.

City Neurology is an online consultation platform for patients suffering from headache, migraine, and other non acute neurological conditions. With a team of specialists and board certified doctors, distant telemedicine consultations can allow diagnosis, treatment, discussion and healing. City Neurology offers an easy, fast, and affordable approach to expert treatment directly from the comfort and relaxation of your home.

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