New Episodic Migraine Prevention Guidelines Released

Patient Expert

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:

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

  • frovatriptan (Frova)

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

  • naratriptan (Amerge, Naramig)
  • zolmitriptan (Zomig)

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

  • estrogen

A third section of the guidelines consists of medications and treatments where we have either inadequate evidence that they're effective or where there's evidence that they're not effective. It's important to note here that this does NOT mean that these medications don't work for anyone. There will undoubtedly be some responses to these guidelines - and remember that they are just that - guidelines.

Level U: Conflicting or inadequate evidence
insufficient data to support or refute using for Migraine prevention:

  • acenocoumarol
  • acetazolamide (Diamox)
  • aspirin
  • bisoprolol
  • Coumadin
  • cyclandelate
  • fluoxetine
  • fluvoxamine
  • gabapentin (Neurontin)
  • hyperbaric oxygen
  • indomethacin (Indocin)
  • nicardipine
  • nifedipine
  • nimodipine
  • Omega-3
  • picotamide
  • protriptyline
  • verapamil

Medications or treatments established as possibly or probably ineffective for Migraine prevention
Should not be offered or considered for Migraine prevention:

  • acebutolol
  • clomipramine
  • clonazepam
  • lamotrigine
  • montelukast
  • mabumetone
  • oxcarbazepine
  • telmisartan

Summary and comments

These guidelines can be a very valuable tool in the hands of physicians. In addition to physicians who are treating people who are already working with their doctors to find effective preventive treatments, they may well open the door to Migraine preventive treatment for many more. Dr. Stephen Silberstein, a co-author of the guidelines and director of the Jefferson Headache Center in Philadelphia commented,

"Approximately 40 percent of people with migraines need preventive treatment, and only about one-third of them are actually getting it."

Given what some other research shown and what we've learned about issues such as use of NSAIDs possibly contributing to episodic Migraine transforming to chronic Migraine as well as the issue of medication overuse headache, I was surprised to see several NSAIDs listed to be recommended to prevent episodic Migraine. I posed this question to Dr. Elizabeth Loder:

"I see some NSAIDs listed for prevention. How does this track with previous papers that have said, for example that NSAIDs were protective against transition to chronic migraine at low to moderate monthly headache days, but were associated with increased risk of transition to chronic Migraine at high levels of monthly headache days?"5

Dr. Loder replied:

"That is an excellent question, and it points out one of the weaknesses in these or any guidelines, which is that they usually look at trials that extended weeks or at best a few months. They rarely follow patients long enough to identify longer term outcomes such as transformation. So the information about transformation comes from long term observational studies, which typically are not incorporated into guidelines. That's one of the 'clinical considerations' that doctors and patients have to bear in mind.

I rarely use NSAIDs for long term prevention because I also worry about GI bleeding. I do use them for shorter periods such as 2 weeks to a month, when people's headaches flare up temporarily."6

One treatment that's been discussed quite a bit for Migraine treatment recently that does not appear in these guidelines is onabotulinum toxin A (Botox). It is not included in these guidelines because they are specifically for episodic Migraine, and Botox was found to be ineffective for episodic Migraine. It's covered in another American Academy Guideline pertaining to chronic Migraine. Botox was found, in clinical trials, to be effective for chronic Migraine and, as noted above, has been approved by the FDA for that use.

Hopefully, these guidelines will prove to be a valuable too to both patients and health care professionals as the work together toward better Migraine management.


  • 1 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.
  • 2 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.
  • 3 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.
  • 4 Kotz, Deborah. "How to get better treatment for migraines. The Boston Globe. April 30, 2012.
  • 5 Gardner, Amanda. "Migraine Guidelines: What Works, What Doesn't." April 24, 2012.
  • 6 Email interview with Dr. Elizabeth Loder. April 23, 2012.

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