FDA-Approved Medications
The Food and Drug Administration has approved four medications for migraine prevention, or prophylaxis. They are propranolol (Inderal), timolol (Blocadren), topiramate (Topamax) and divalproex sodium (Depakote). These are considered the “first-line” treatments in migraine prophylaxis. There are times when you may not be able to tolerate them because of side effects or because one of the first-line treatments is ineffective. When this occurs, your healthcare provider may prescribe another medication that may be helpful. This is typically called using a medication “off-label.” This is quite common and may be the best solution for you.Beta-Blockers
Beta-blockers are medications usually used in treating high blood pressure (hypertension), but there are a number of other uses for them as well. Propranolol and timolol are both beta-blockers. Others that may be tried in migraine treatments include atenolol (Tenormin), long-acting metoprolol (Toprol XL) or nadalol (Corgard). Common side effects include fatigue, nausea, dizziness, insomnia and depression. Contraindications to their use include hypoglycemia associated with diabetes, hypotension, asthma or some heart conditions.Antidepressants
Amitriptyline is an antidepressant known as a tricyclic antidepressant (TCA). While not FDA-approved for migraine prevention, there have been multiple studies showing that amitriptyline can be an effective prophylactic medication. It seems to be especially effective when you have migraines that take on various forms or have features common in tension headaches. Amitriptyline may also be effective when migraine sufferers have insomnia or depression that accompanies the headaches. Common side effects include drowsiness, weight gain and dry mouth.The Selective Serotonin Reuptake Inhibitors (SSRIs), such as fluoxetine (Prozac), are occasionally used in migraine prevention, but research does not support their widespread use.
Anticonvulsants
Anticonvulsants are medications originally intended to treat epileptic seizures. They have other uses as well, including preventing migraine headaches. Divalproex (Depakote) is FDA-approved, and numerous studies support its use. Gastrointestinal side effects are common but decrease as time passes. Pregnant patients and those with liver disease or a history of pancreatitis should not use it at all.Some studies have shown that gabapentin (Neurontin) is useful in preventing migraines at certain dosages, although more research is definitely needed. Dizziness and drowsiness are the most common side effects. Topiramate (Topamax) is another anticonvulsant that seems to be a good choice for migraine prevention. Common side effects include fatigue and nausea, although lower dosages didn’t cause as many problems.
Other Choices
There are a number of other medications that are used to prevent migraines, none of which have been FDA-approved at this point. Lisinopril (Zestril), an ACE-inhibitor used for treating hypertension, has shown some promise in preventing migraines. Candesartan (Atacand) is an angiotension receptor blocker (ARB) that, according to one study, may be effective in migraine prophylaxis.Calcium channel blockers are blood pressure medications that have historically been used for migraine prevention. There is little to no scientific evidence to support their use, although there is some weak evidence suggesting verapamil (Calan) may be helpful.
Chronic nonsteroidal anti-inflammatory drug (NSAID) use can be dangerous because of the gastrointestinal problems they can cause, but there are some cases where NSAIDs may be useful in preventing migraines, especially naproxen (Naprosyn). Taking NSAIDs before and during early menstruation may be helpful in preventing menstrual migraines.
Sources:
Drugs for migraine. Treatment guidelines from The Medical Letter, 2004;2:63-66.
Migraine. National Headache Foundation. Retrieved: December 9, 2008. http://www.headaches.org/education/Headache_Topic_Sheets/Migraine
Modi S, Lowder DM. Medications for migraine prophylaxis. Am Fam Physician. 2006 Nov 15;74(10):1685. Retrieved: December 9, 2008. http://www.aafp.org/afp/20060101/72.html
Tronvik E, Stovner LJ, Helde G, Sand T, Bovim G. Prophylactic treatment of migraine with an angiotension II receptor blocker: a randomized controlled trial. JAMA, 2003;289:65-9.
