The physician analyzes the patient's migraine history to devise an appropriate treatment program. The goals of treatment are to prevent or reduce the number of migraines (called prophylactic treatment) and to alleviate symptoms and shorten the duration of the migraine (called abortive or acute treatment).
Preventative medication may be prescribed for patients who have frequent headaches (3 or more a month) that do not respond to abortive treatment. Studies have shown that as many as 40 percent of these patients may benefit from preventative treatment.
Using one medication (monotherapy) is tried first, but a combination of medicines may be necessary. Many of these medications have adverse side effects. If migraines become controlled, the dosage is often reduced or the drug discontinued.
Beta blockers (e.g., propranolol [Inderal], atenolol [Tenormin]) are the preferred medications to prevent migraines. These drugs produce an effect on heart rate. They should not be taken by patients with asthma and should be used with caution in patients with diabetes.
Side effects include gastrointestinal upset, insomnia, low blood pressure (hypotension), slowed heart rate (bradycardia), and sexual dysfunction. Some beta blockers pass into breast milk and may cause problems in nursing infants.
Antiseizure drugs such as valproic acid (Depakote), topiramate (Topamax), and gabapentin (Neurontin) may be used to prevent migraine headaches. Topiramate was approved by the FDA in March 2014 to treat migraines in adolescents between the ages of 12 and 17the first medication approved for prevention in this age group.
Medications that contain valproate sodiumincluding Depacon, Depakote, Depakote CP, and Depatote ERvalproic acid (Depakene, Stavzor), and generic versions of these drugs should not be used in women who are pregnant. These medicines contain a boxed warning indicating that they may cause birth defects. In May 2013, the U.S. Food and Drug Administration (FDA) warned that children born to mothers who used these drugs to prevent migraines during pregnancy are at increased risk for lower-than-normal IQs.
Side effects include nausea, gastrointestinal upset, sedation, liver damage, and tremors.
Calcium channel blockers (e.g., verapamil, amlodipine [Norvasc]) inhibit artery dilation and block the release of serotonin. They should not be taken by patients with heart failure or heart block.
Side effects include constipation, flushing, low blood pressure, rash, and nausea.
Tricyclic antidepressants (TCAs; e.g., amitryptaline [Elavil], nortryptaline [Pamelor], desipramine [Norpramin]) block serotonin reabsorption and take 23 weeks be effective.
Side effects include the following:
- Dry mouth
- Low blood pressure (hypotension)
- Increased heart rate (tachycardia)
- Urinary retention
- Sexual dysfunction
- Weight gain
High doses of TCAs have been implicated in seizures, stroke, and heart attack. Abrupt discontinuation of these medications may cause headache, nausea, and malaise, and may intensify side effects.
Selective serotonin reuptake inhibitors (SSRIs; e.g., paroxetine [Paxil], fluoxetine [Prozac], sertraline [Zoloft]) are usually better tolerated than TCAs, but may not be as effective.
Side effects include nausea, insomnia, sexual dysfunction, and loss of appetite.
Methysergide maleate (e.g., Deseril, Sansert) may be prescribed for patients with frequent, severe migraines.
Side effects include insomnia, drowsiness, lightheadedness, and hair loss. This drug should not be used by patients with coronary artery disease and must be discontinued for 34 weeks after 46 months of use because it can cause retroperitoneal fibrosis, a condition in which the blood vessels in the abdomen thicken, which reduces blood flow to organs.
In October 2010, the U.S. Food and Drug Administration (FDA) approved botulinum toxin injection therapy (also known as "BOTOX therapy" or onabotulinumtoxinA) to treat chronic migraine in adults who experience headaches 14 or more days per month. This treatment, which involves several injections, is administered every 12 weeks. The most common side effects of treatment are head and neck pain.
In March 2014, the FDA approved the first device to prevent migraine headaches in people 18 years of age and older. Called Cefaly, this battery-powered headband is worn above the ears and across the forehead. Cefalyavailable by prescription to help reduce the frequency of migrainesis the first transcutaneous electric nerve stimulation (TENS) device approved by the FDA for use prior to the onset of pain. This device is uses electric current to stimulate the trigeminal nervewhich is associated with migraine headaches.
Cefaly is used once per day, for 20 minutes. In clinical studies, people who used this device experienced fewer days with migraine pain each month and were able to use less medication to prevent headaches. Some people experienced a tingling or massaging sensation at the electrode application site, which may be uncomfortable or irritating. Others experienced sleepiness during treatment or a headache after wearing the device.