There are now over 100 medications and supplements in use for Migraine and headache prevention. Astonishingly, only four of them have been approved by the FDA for that purpose. Those four medications are:
- propranolol, brand name Inderal
- timolol, brand name Blocadren
- divalproex, brand name Depakote
- topiramate, brand name Topamax
Additionally, OnabotulinumtoxinA, brand name Botox, is FDA approved for chronic Migraine only.
Now, a study has shown that candesartan (brand name Atacand) is effective for Migraine prevention with success similar to that of propranolol. This was also demonstrated in one small study several years ago, but the results of a singly study, especially a small one, are seldom given much weight until replicated in another study. Candesartan is an angiotensin II receptor blocker medication that is FDA approved for the treatment of hypertension and congestive heart failure.
"The objective of this article is to see whether the effect of candesartan for migraine prevention, shown in one previous study, could be confirmed in a new study, and if so, whether the effect was comparable to that of propranolol (non-inferiority analysis), and whether adverse events were different."1
- This was a randomized, triple-blind, double cross-over study.
- There were 72 adult study participants with episodic or chronic Migraine.
- Participants were randomly assigned to one of three trial groups for three 12-week treatment periods with:
- 160 mg slow-release propranolol,
- 16 mg candesartan, or
- Propranolol and candesartan were both superior to placebo.
- Neither candesartan nor propranolol produced better results than the other. Their success rates were nearly identical.
- More side effects (adverse events) were reported in the propranolol and candesartan groups than in the placebo group.
- Candesartan and propranolol were similar in the number of side effects reported, but the side effects profiles for candesartan and propranolol were somewhat different.
- The most frequently reported side effects of candesartan were dizziness and paresthesia.
- The most frequently reported side effects of propranolol were body pain and low pulse rate when exercising.
"It is confirmed that candesartan 16 mg is effective for migraine prevention, with an effect size similar to propranolol 160 mg, and with somewhat different adverse events."1
Clinical implications of the study:1
- Candesartan is effective for migraine prevention.
- The effect is similar to that of propranolol.
- The adverse event profile is different from that of propranolol.
- Candesartan may become a drug of first choice for migraine prevention.
Summary and comments:
As is the case with many of the medications used for Migraine prevention, the mechanism by which candesartan works is poorly understood. Still, this study and the previous study of candesartan show that it works as well for Migraine prevention as propranolol, which is FDA approved for the treatment of Migraine. It’s doubtful that candesartan will be approved by the FDA for Migraine prevention since the patent on Atacand has now expired. Once the patents on brand name medications have expired, the funding necessary for the studies needed to apply for FDA approval is seldom forthcoming. Don’t let this stop you from discussing it with your doctor if you’re interested. It can be prescribed off-label, which is the case with the vast majority of the medications used for Migraine prevention.
One advantage of candesartan over propranolol is that it has fewer contraindications so it can be prescribed for patients with conditions that rule out beta blockers such as propranolol. Those conditions include asthma, diabetes, and heart conduction block.
1 Stovner, Lars J.; Linde, Mattias; Gravdahl, GÃ¸rbil B.; Tronvik, Erling; Aamodt, Anne H.; Sand, Trond; Hagen, Knut. “A comparative study of candesartan versus propranolol for migraine prophylasis: A randomised, triple-blind, placebo-controlled, double cross-over study.” Cephalalgia. Online First. First published on December 11, 2013 as doi:10.1177/0333102413515348.
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Teri Robert is a leading patient educator and advocate and the author of Living Well with Migraine Disease and Headaches. A co-founder of the Alliance for Headache Disorders Advocacy and the American Headache and Migraine Association, she received the National Headache Foundation’s Patient Partners Award and a Distinguished Service Award from the American Headache Society. Teri can be found on her website, and blog, Facebook, Twitter, StumbleUpon, Pinterest, LinkedIn, and Google+.