As mentioned multiple times before, keeping a diary to keep track of how often you are suffering with migraine attacks and how long they are lasting can be helpful in identifying whether or not you are likely to benefit from preventative treatment.
There is guidance to decide whether or not you fit this criteria:
- Experience frequent disabling attacks:
- two or more attacks per month which last 3 or more days at a time
- quality of life is severely impaired
- Are at risk of Medication Overuse Headache
- Normal pain-killers or triptans cannot be prescribed or are ineffective
- Atypical migraine: hemiplegic migraine (a sub-type of Migraine with aura which causes paralysis of one side of the body) or a persistent aura.
What does it do?
I like to think of preventative medication as a sort of “reset” button: they make you less likely to have a migraine. Essentially the aim of any preventative treatment is to reduce both the severity of the migraine and the frequency of attacks. The best preventative can only reduce the frequency and severity of attacks by 50% so it is definitely not a cure. It is still important to try an assess potential triggers and try to minimise them where possible.
None of the medications we suggest for migraine prevention have been developed specifically for the treatment of migraine. There are a few main classes of medications which I will allude to:
- Tricyclic Antidepressants (TCAs)
- Selective Noradrenaline Re-uptake Inhibitors (SNRIs)
There are also injectable treatments which I will discuss in a separate post.
The most common of these used is Propranolol. Beta-blockers are often the first preventative medication tried. They are well tolerated with few side-effects (vivid dreams, fatigue, reduced exercise tolerance, dizziness and erectile-dysfunction in men). It is not suitable for asthmatics.
The main one used nowadays is Topiramate. I call this medication “marmite”: patients either love it or hate it. It works well if you don’t get side-effects, and some people don’t. Others on the other hand find the tingling in hands and feet, weight loss, mood changes (specifically unmasking of anxiety or depression) and cognitive slowing too difficult to deal with. There’s no way of telling if you’ll be lucky or not. This is also the only one that does not cause weight gain: in fact it usually gives the opposite effect.
This includes my favourite class of migraine preventative: TCAs. This is an old fashioned antidepressant but we use it a much lower dose in this setting. Amitriptyline or (as a patient once described it to me) it’s “more refined brother” Nortriptyline is taken 2 hours before bedtime to mitigate its main side-effect: drowsiness. This is actually a pretty good thing as it guarantees a fantastic nights sleep. The other major side-effect is dry mouth. Some people have vivid dreams and weight gain with it.
The other class of antidepressant SNRI is useful if people also suffer with anxiety or depression. Venlafaxine or Mirtazepine tend to be more effective as migraine preventers than first-line antidepressants such as sertraline, fluoxetine or citalopram.
This includes the relatively new kid on the block: Candesartan. This has a very low side-effect profile apart from dizziness due to…well…low blood pressure. The other medication which is used more commonly overseas is (as a patient once described it to me is Flunarazine which is a calcium-channel blocker. Unfortunately it’s difficult to get hold of in the UK so its use is limited.
Some patients still come to the clinic on medications such as gabapentin, pizotifen, sodium valproate, verapamil… these are often unsuccessful. Pizotifen does have a place in migraine prevention, but for some reason it tends to work better for children. Gabapentin has been shown to be ineffective for migraine (although it still features in the guidelines which have yet to be updated) and verapamil is useful for Cluster Headache but not Migraine.
But what if I don’t want to take medication?
Lots of people don’t like taking medications because of the side-effects listed above. There have been studies on supplements and vitamins and people are always keen to know what the more natural remedies are.
- Riboflavin (Vitamin B2): at a dose of 400mg this has been shown to reduce the frequency (but not severity or duration) of migraine attacks. Main side-effect: turns urine more yellow.
- Magnesium: usually as citrate or maleate as they are better tolerated. There is evidence that this can reduce the frequency and severity of attacks. It is also beneficial in menstrual migraine for pre-menstrual attacks. Dose is 600mg to be taken at night and main side-effects are abdominal cramps and diarrhoea.
- Co-enzyme Q10: again reduces the frequency but not the severity of attacks. Dose is 300mg per day.
The other option that people often ask us about is Botox. But that is a discussion for another article…