Possibly the most discussed topic about Migraine is Migraine prevention and the medications used for that purpose. Although there isn't even one, single medication on the market that was originally developed for Migraine prevention, there are now over 100 medications and supplements in use - medications that were originally developed for other conditions, then discovered to also be helpful in preventing Migraines.

This situation has created an extremely confusing situation for patients and health care providers alike. Four of these medications have been approved by the FDA for the treatment of Migraine: propranolol (brand name Inderal), timolol (brand name Blocadren), divalproex sodium (brand name Depakote), and topiramate (brand name Topamax). One has been approved by the FDA for the treatment of chronic Migraine: onabotulinum toxin A (brand name Botox). Still, for many Migraineurs, the search for effective treatment leads them and their doctors beyond these few options.

For the majority of Migraineurs who seek treatment with doctors other than Migraine specialists, the long list of medications from which to choose coupled with how differently each person can react to these medications results in a situation of trial-and-error in which it can take years to find effective treatment.

Recently, the American Headache Society and the American Academy of Neurology joined forces to establish guidelines to assist health care professionals in choosing treatments for episodic Migraine prevention. Both societies issued these guidelines through their journals.

These guidelines were developed by collecting and coordinating data from the available studies and evidence from June, 1999, to May 2009. They represent the most comprehensive evaluation of the data available on these treatments.

To help us better understand how medications were assigned to the different levels I'm about to list, I quote the AHS journal article:

"...the 2012 AHS/AAN guidelines assign treatments to Levels based on assessment of the strength and quality of evidence of efficacy. Adverse effects, contraindications to use and other clinical considerations are reviewed but are not incorporated in the assignment of drugs to a particular level."¹

The Guidelines

The guidelines list medications in different levels. Below is a summary of each level, what the levels mean, and the medications assigned to those levels:

Level A: Established as effective
Should be offered to patients requiring Migraine prevention:

• divalproex/sodium valproate
• metoprolol
• petasites (butterbur)
• propranolol
• timolol
• topiramate

Level B: Probably effective
Should be considered for patients requiring Migraine prevention:

• amitriptyline
• fenoprofen
• feverew
• histamine
• ibuprofen
• ketoprofen
• magnesium
• naproxen/naproxen sodium
• riboflavin
• venlafaxine

Level C: Possibly effective
May be considered for patients requiring Migraine prevention:

• candesartan
• carbamazepine
• clonidine
• granfacine
• lisinopril
• nebivolol
• pindolol
• flurbiprovin
• mefanamic acid
• Coenzyme Q10
• cyproheptadine

The guidelines also included medications recommended for short-term prevention of menstrually triggered Migraines: