More than 2,000 years ago, Hippocrates described “a violent pain supervened in the right temple, then in all the head and neck” accompanied by a “light in part of the right eye” and “vomiting.”
As the Greek physician’s description suggests, migraines are no ordinary headaches. Along with the throbbing pain come nausea, vomiting, visual auras, and sensitivity to light and sound. In people with chronic migraines, these debilitating symptoms can strike 15 or more days each month.
Preventive medicines are available to reduce the frequency and severity of migraines. Yet, while 40 percent of migraine sufferers could find relief from these treatments, only 13 percent use them, says a review in the September 2016 Headache by researchers at the Mayo Clinic and Baylor College of Medicine.
“Concerns over medication side effects, coupled with the need to take these medicines every day for several months or sometimes years, may prevent people who could benefit from migraine drugs from taking them,” says Peter Rabins, M.D., M.P.H., a professor at the Erickson School of Aging, University of Maryland, Baltimore County, and founding director of geriatric psychiatry at Johns Hopkins University School of Medicine in Baltimore.
The two types of drugs
Migraine treatments come in two forms. Abortive, or acute drugs, relieve migraine pain. You take them when a headache starts. Preventive, or prophylactic, drugs reduce the frequency and severity of migraines. You take these every day.
“Patients are considered good candidates for preventive medicines if they get more than four migraine headaches each month, or if their headaches last longer than 12 hours, and they cause significant disability,” Rabins says.
In their review, the researchers emphasized that preventive drug treatment needs to be tailored to each individual, including the therapy’s duration, which may often be longer than the recommended treatment length.
Notably, they cited a 2014 study that found that 76 percent of patients who took a preventive drug for two years were still pain-free three years after stopping the drug. Among patients who took the drug for just one year, only 44 percent remained pain-free three years later.
Available treatments may help decrease the frequency and severity of headaches, but it can sometimes take up to four weeks before you feel any improvement—and some people can’t tolerate their side effects. You may find that you need a combination of preventive and acute therapy. Finding a regimen that works may require a process of trial and error. The following are the available drug therapies used in the prevention of chronic migraines:
• Antiseizure drugs. Topiramate (Topamax) and valproic acid (Depakote, Depakene) reduce the frequency of migraines. Both drugs have been linked to several side effects, including weakened bones, a tingling sensation in the arms and legs, kidney stones, mood changes, fatigue, trouble sleeping, memory problems, nausea, dizziness, and hair loss.
• Antidepressants. Amitriptyline (Elavil) is effective at preventing migraines and can be helpful if you have insomnia or depression. Elavil can cause side effects such as sleepiness, dry mouth, dry eyes, constipation, and weight gain. This drug can also increase your risk for irregular heart rhythms and other heart complications, so anyone who is over age 65 or has heart disease might need to avoid it. Venlafaxine (Effexor) has side effects similar to those of Elavil and might also raise blood pressure.
• Blood pressure medicines. These drugs serve double duty, also lowering blood pressure. Beta-blockers like propranolol (Inderal) and metoprolol (Lopressor, Toprol) have the best evidence for migraine prevention. However, those drugs may not be the ideal choice for people over age 60—especially those who smoke—because they don’t protect as well as other blood pressure drugs against stroke. Calcium channel blockers and angiotensin-converting enzyme (ACE) inhibitors are also used for migraine prevention, although their effectiveness hasn’t been as well proved as the beta-blockers.
• Botulinum toxin type A (Botox). Two large studies showed Botox is effective for reducing the frequency of chronic migraines. This treatment is expensive, and insurance might not cover the cost unless other treatments haven’t worked for you. Patients typically get injections every 12 weeks. Botox side effects are rare but may include trouble swallowing, pain at the injection site, and headache.
“Your doctor will help you choose a migraine drug based on your preferences and other conditions you have, such as heart disease, depression, and insomnia,” Rabins says. “The doctor will typically start you on a low dose and increase it gradually until you see a benefit, while watching for side effects.”
At-home steps to prevent migraines
• Keep a migraine diary to learn your triggers so you can avoid them. Common triggers include stress, odors, certain foods, hormones, and changes in sleep patterns.
• Use relaxation techniques like meditation and massage to ease stress.
• Don’t skip meals.
• Exercise regularly.
• Set a sleep schedule. Go to sleep and wake up at the same times each day.