Migraine and Headache Prevention - So Many Options

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Migraine preventive treatment is suggested for those of us who have three or more migraines a month, or whose migraines are especially severe or debilitating. Amazingly, the medications used for this purpose were all originally developed for other conditions, then found to be effective as migraine preventives. The discovery is often made when patients taking the medications for their original purpose notice a reduction in the frequency or severity of their migraines. The list is ever-evolving. Even as I publish this list of treatments that I've compiled, there are bound to be some that I've not read or heard about yet.

When you consider the list below and the nearly endless possible combinations of these treatments, it's easier to see how migraine specialists can tell us that effective preventive regimens can now be found for 95-98% of patients. It can take up to three months to know if a treatment is effective for us, but with time, patience, and a good doctor, there is hopeThe vast majority of medications prescribed as preventives are prescribed off-label. That means that although they have been approved by the FDA, they have not been approved specifically for Migraine and headache prevention. Only five medications have been approved specifically for this purpose:

  • propranolol, brand Inderal
  • timolol, brand Blocadren
  • divalproex, brand Depakote
  • topiramate, brand [Topamax](file:///C%7C/Users/teri_000/AppData/Local/Microsoft/Windows/INetCache/IE/TCRSIP0Q/topamax-oral-14494%5B1%5D)
  • onabotulinumtoxinA, brand Botox (approved for chronic migraine only.)

The following medications are being used successfully by some headache and Migraine patients as preventive medications. They're listed first by their generic names, followed by some of their brand names.

ANTIHYPERTENSIVES (blood pressure meds)
Alpha-2 agonists:

  • clonidine, brand Catapres
  • guanfacine, brand Tenex

ACE Inhibitors:

  • benazepril, brand Lotensin
  • captopril, brand Capoten
  • enalapril, brand Vasotec
  • fosinopril, brand Monopril
  • lisinopril, brand Zestril, Prinivil
  • moexipril, brand Univasc
  • perindopril, brand Aceon
  • quinapril, brand Accupril
  • ramipril, brand Altace
  • trandolapril, brand Mavik

Angiotensin II Inhibitors:

  • candesartan, brand Atacand
  • eprosartan, brand Teveten
  • irbesartan, brand Avapro
  • losartan, brand Cozaar
  • olmesartan, brand Benicar
  • telmisartan, brand Micardis
  • valsartan, brand Diovan

Beta Blockers:

  • acebutolol, brand Secral
  • atenolol, brand Tenormin
  • betaxolol, brand Kerlone
  • bisoprolol, brand Zebeta, Emconcor
  • cartelol, brand Cartrol
  • carvedilol, brand Coreg
  • esmolol, brand Brevibloc
  • labetalol, brand Normodyne, Trandate
  • metoprolol, brand Toprol
  • nadolol, brand Corgard
  • penbutololm brand Levatol
  • pindolol, brand Visken, Syn-Pindolol
  • propranolol, brand Inderal
  • sotalol, brand Betapace
  • timolol, brand Blocadren

Calcium Channel Blockers:

  • amlodipine, brand Norvasc
  • bepridil, brand Vascor
  • diltiazem, brand Cardizem, Tiazac, Cartia
  • felodipine, brand Plendil
  • flunarizine, brand Sibelium (Canada)
  • isradipine, brand DynaCirc
  • nicardipine, brand Cardene
  • nifedipine, brand Adalat, Procardia
  • nimodipine, brand Nimotop
  • nisoldipine, brand Sular
  • verapamil, brand Calan, Verelan, Isoptin

Antihyprtensive Combinations:

  • trandolapril/verapamil, brand Tarka (ACE inhibitor/calcium channel blocker)
  • enalapril/felodipine, brand Lexxel (ACE inhibitor/calcium channel blocker)
  • amlodipine/benazepril, brand Lotrel (calcium channel blocker/ACE inhibitor

ANTIHISTAMINES:

  • cyproheptadine, brand Periactin
  • pizotifen, brand Sandomigran (UK)

ANTIDEPRESSANTS
Tricyclic antidepressants (TCAs):

  • amitriptyline, brand Elavil (discontinued), Endep
  • amoxapine, brand Asendin
  • clomipramine, brand, Anafranil
  • desipramine, brand Norpramin
  • doxepin, brand Sinequan
  • imipramine, brand Norfranil, Tofranil
  • nortriptyline, brand Pamelor, Aventyl
  • protriptyline, brand Vivactil
  • trimipramine, brand Surmontil

MAOI Antidepressants:

  • isocarboxazid, brand Marplan
  • phenelzine, brand Nardil
  • tranylcypromine, brand Parnate

Selective serotonin reuptake inhibitors (SSRIs):

  • citalopram, brand Celexa
  • escitalopram oxalate, brand Lexapro
  • fluoxetine, brand Prozac
  • fluvoxamine, brand Luvox
  • paroxetine, brand Paxil, Paxil CR, Pexeva
  • sertraline, brand Zoloft

Selective serotonin and norepinephrine reuptake inhibitors (SNRIs):

  • desvenlafaxine, brand Pristiq
  • duloxetine hydrochloride, brand Cymbalta
  • milnaciptan, brand Savella
  • venlafaxine, brand Effexor, Effexor XR

Other Antidepressants:

  • bupropion, brand Wellbutrin, Zyban
  • mirtazepine, brand Remeron
  • trazodone, brand Desyrel

Other Neurologics:

  • acetazolamide, brand Diamox
  • methazolamide, brand Neptazane

Attention Deficit Hyperactivity Disorder Meds
Selective Norepinephrine Reuptake Inhibitor:

  • amphetamine/dextroamphetamine, brand Adderall
  • atomoxetine HCl, brand Strattera
  • methylphenidate, brand Concerta

ARTHRITIS MEDS
Cox-2 Enzyme Inhibitors:

  • celecoxib, brand Celebrex

NEURONAL STABILIZING AGENTS (antiseizure medications)

  • carbamazepine, brand Tegretol
  • clonazepam, Klonopin
  • clorazepate, brand Tranxene
  • divalproex, brand Depakote
  • gabapentin, brand Neurontin
  • levetiracetam, Keppra
  • lamotrigine, brand Lamictal
  • pregabalin, brand Lyrica
  • oxcarbazepine, Trileptal
  • tiagabine, brand Gabitril
  • topiramate, brand Topamax
  • valproate Sodium, brand Depacon
  • lacosamide, brand Vimpat
  • zonisamide, brand Zonegran

Ergot Alkaloid:

  • methylergonovine, brand Methergine (the only ergot used as a preventive, no longer available)

Leukotriene Blockers:

  • montelukast, brand Singulair
  • zafirlukast, brand Accolate
  • zyleuton, brand Zyflo

Atypical Antipsychotic Medications:

  • olanzapine, brand Zyprexa
  • quetiapine, brand Seroquel
  • ziprasidone, brand Geodon

Dietary Supplements:

  • coenzyme Q10
  • feverfew (Should not be used by women who are or could become pregnant.)
  • butterbur, brand Petadolex
  • magnesium
  • vitamin B2
  • 5-HTP (Check carefully with doctor because of interactions with meds including triptans)
  • lecithin
  • melatonin

Devices and Appliances:

  • Spring TMS Device: The Spring TMS is a single-pulse Transcranial Magnetic Stimulation (sTMS) device approved by the FDA for the acute treatment of migraine with aura in 2014. For more information, see Acute Migraine Treatment – Spring TMS Device Finally Approved FDA.
  • Cefaly: The Cefaly is an external trigeminal nerve stimulator (eTNS) device that was approved by the FDA for migraine prevention in 2014. For more information, see Cefaly Device Approved by the FDA for Migraine Treatment.
  • NTI Tension Suppression System (NTI-TSS): If a temperomandibular joint disorder (TMJ), bruxism (grinding your teeth), or clenching your jaw are Migraine triggers for you, you may want to check into the NTI Tension Suppression System (NTI-TSS). This is a small dental appliance worn at night to keep the molars and canines from touching. It was developed by Dr. Jim Boyd, and has been helpful for people with these triggers. (See www.nti-tss.com.)

This list will be updated as more treatments are successfully used for headache and Migraine prevention. If you're having problems finding an effective preventive regimen, sharing this list with your doctor may be helpful to you.


Sources:

Loder, Elizabeth, MD, MPH; Burch, Rebecca, MD; Rizzoli, Paul, MD. "The 2012 AHS/AAN Guidelines for the Prevention of Episodic Migraine: Summary and Comparison with other Recent Clinical Practice Guidelines." Headache. Accepted manuscript online: April 26, 2012.

Silberstein, S.D.; Holland, S.; Freitag, F.; et. al. "Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults : Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society." Neurology 2012;78;1337.

Holland, S.; Silberstein, S.D.; Freitag, F.; et al. "Evidence-based guideline update: NSAIDS and other complementary treatments for episodic migraine prevention in adults : Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society." Neurology 2012;78;1346.

Kotz, Deborah. "How to get better treatment for migraines. The Boston Globe. April 30, 2012. http://tinyurl.com/c7mkta2.

Gardner, Amanda. "Migraine Guidelines: What Works, What Doesn't." Philly.com. April 24, 2012.

Email interview with Dr. Elizabeth Loder. April 23, 2012.

Ramadan, Nahib M., MD; Silberstein, Stephen D., Md, FACP; Frietag, Frederick G., DO; Gilbert, Thomas T., MD, MPH; Frishberg, Benjamin M., MD. "Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management for Prevention of Migraine." American Academy of Neurology Practice Guidelines. September, 2000.

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