Migraine Preventives - Three Major Questions
It's recommended that anyone who has three or more Migraines a month work with our doctors to find effective preventive treatment. With prevention being such an important part of our Migraine treatment regimen, it's only natural that we have many questions about preventive medications for Migraine. The whole subject of Migraine preventive medications can be confusing for many reasons, including:
- There are no medications on the market that were originally developed for Migraine or chronic Migraine prevention. All the medications in use were originally developed for other conditions and have been handed down to us when it was noticed that they helped Migraines in the patients with those conditions.
- The medications that work for Migraine prevention belong to many different drug classes — beta blockers, calcium channel blockers, neuronal stabilizing agents (anti-seizure medications), various classes of antidepressants, biologics (Botox), and more.
Three of the most commonly asked questions about Migraine preventive medications are:
- If a preventive medication works, how long will it work?
- Will I be taking this type of medication forever?
- With chronic Migraine, we really won't be able to tell if a preventive is helping any and won't want to upset the apple cart by going off it and risking it not working if we want to try it again later?
Let's take a look at these three questions:
If a preventive medication works, how long will it work?
We'd all love to have an answer to this question. Unfortunately, the answer is one that none of us like - We don't know how long a medication will work. Just as Migraines differ from one person to the next, how well and how long preventive medications varies. For some people, once they find a medication that works, it works for years, possibly indefinitely. Other people have problems finding a medication that works longer than a few months. There are many variables that can impact the effectiveness of medications - other medications, other health conditions, our body chemistry, and more.
Before deciding that a Migraine preventive medication has stopped working, here are some other possibilities to consider:
- Could you be having more frequent or more intense Migraines because you're encountering a new trigger or have developed a new trigger?
- Is it possible that when the medication started working, you stopped being as vigilant about managing your Migraine triggers and avoiding any that are avoidable?
- If medications seem to "wear out" quickly, and you can't identify your triggers, it's worth asking your doctor about a lumbar puncture (spinal tap) to rule out idiopathic intracranial hypertension.
Will I be taking this kind of medication forever?
This is another question for which there is no "right" answer. Discontinuing preventives seems to go one of three ways:
- In some cases, the Migraineur finds their Migraines continue to be less frequent and severe.
- Some Migraineurs find their Migraines continue to be less frequent and severe for a period of time, then gradually increase in frequency and severity until they need preventives again.
- Other Migraineurs find their Migraines increasing in frequency and severity as soon as they discontinue their preventive medications.
Unfortunately, there's no reliable way to predict what will happen if and when Migraine preventive medications are discontinued. Another unfortunate fact is that there's a risk to discontinuing preventive medications that are working. Once discontinued, they may not work again if we discover that we need to continue with preventives, and there's no predicting if they'll work again.
Some doctors tell young patients that they'll "probably outgrow" their Migraines. This isn't a statement that comes true for many, if not most Migraineurs. It does occur more often in boys than girls.
Some women are told that their Migraines will stop once they go through menopause. This predictive statement can't be counted on either.
Following spontaneous (natural) menopause:
- 67% of women find that their Migraines get better;
- 9% of women find that their Migraines get worse; and
- 24% of women find that their Migraines don't change at all.
However, when it comes to surgical menopause following a hysterectomy, it's an entirely different matter. Following surgical menopause:
- 33% of women find that their Migraines get better;
- 67% of women find that their Migraines get worse; and
- a statistically insignificant number of women find that their Migraines don't change at all.
With chronic Migraine, we really won't be able to tell if a preventive is helping any and won't want to upset the apple cart by going off it and risking it not working if we want to try it again later?
Chronic Migraine (CM) can be extremely difficult to treat, but finding preventive medications that work is the goal. An important factor with CM is being sure that medication overuse headache (MOH) isn't contributing to being chronic. By definition, CM is Migraine OR headache that occurs 15 or more days per month, with Migraines on at least eight of those days. It's thought that the headaches (as opposed to Migraines) that occur with CM are actually Migraines that don't fully develop the phases of Migraine and their associated symptoms. If the CM patient also has MOH, it may be more difficult to find effective preventives. It's worth noting that the only medication with enough evidence behind it to be FDA approved for the treatment of CM is Botox, which has not been shown to be effective for episodic Migraine. That doesn't mean that others can't help; it simply means that Botox has the clinical trial evidence behind it to be approved by the FDA. Many of the medications we use have anecdotal evidence, but not enough evidence from clinical trials, partly because of the great expense involved in clinical trials.
As with so many questions about Migraine, we simply don't have easy answers to these questions. Instead, we have answers such as "Maybe," "Sometimes," and "It depends on the individual Migraineur." The best "answer" is to partner with a doctor who truly understand Migraine disease and how to treat it and work with our doctor to make the best informed, joint decisions possible.
Marcus, Dawn A., MD; Bain, Philip A., MD. "The Woman's Migraine Toolkit." New York, New York. DiaMedica Publishing. 2011.
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© Teri Robert, 2014
Last updated April 9, 2014.