Migraine preventive treatments

In general, if you are experiencing two or more severe migraine attacks a month, you could be a candidate for preventive therapy.

Preventive therapy is used in addition to treatments for acute attack, not in place of it. It's usually considered after other steps in treating migraine. As the person being treated, you are usually the best judge of whether these treatments are working to adequately control your symptoms . 

The aim of preventive therapy for migraine is to reduce the number of attacks, either because:

  • the medicines used to treat attacks don’t control your symptoms adequately, or
  • migraine attacks, even though well controlled, are happening far too often, placing you at risk of developing medication overuse headache.

Preventive therapy will not eliminate migraines completely, but the aim is to reduce the number of attacks to a manageable level — by about a half after 3 months of preventive therapy. In other words, it may take some months for the full effect of a preventive therapy to be seen, so it’s always best to persevere with treatment. Of course if you are experiencing side effects, you should speak to your doctor.

A good way to assess the effectiveness of a preventive therapy is by keeping a headache diary.

Medicines for preventing migraines

Many different medicines can be used as preventive therapy for migraine. In general, these medicines are more commonly prescribed for the treatment of other conditions, e.g. high blood pressure or depression, but also have unrelated anti-migraine effects.

Not all people will be suited to all of these medicines, so your doctor will consult with you about your general health before recommending the most appropriate preventive therapy for you. Side effects with these medicines are less likely if you start the preventive treatment at a low dose and increase the dose gradually over a few weeks.

Preventive treatments do not have to be taken forever. Once your migraines have been well controlled for 3 to 6 months, your doctor may suggest you slowly wean off the medicine, to see if the treatment is still required.

Recommended medicines for the prevention of migraine include:

  • Beta-blockers: Propranolol (Deralin), atenolol (Noten, Anselol), metoprolol (Betaloc, Lopressor)

    Better known as medicines to treat high blood pressure and some heart conditions, beta-blockers are also effective at preventing migraine. However, beta-blockers are not suitable for everybody and should not be used for migraine prevention in people who suffer from asthma, peripheral vascular disease (reduced circulation caused by a narrowed or blocked blood vessels), heart failure, or depression.

    Common side effects of the beta-blockers include cold hands and feet, tiredness, (especially during exercise), dizziness, and sleep disturbance including vivid dreams.

  • Amitriptyline (Endep)

    Amitriptyline may be recommended to you if you cannot take beta-blockers and/or you suffer from disturbed sleep or other painful conditions such as troublesome tension-type headache.

    Amitriptyline was originally developed as a treatment for depression. However, it also has pain modifying properties which are unrelated to its antidepressant effects. Commonly reported side effects include dry mouth, sleepiness (hence it is often taken at bedtime), dizziness, nausea and constipation. These are most apparent in the first couple of weeks, and generally settle with continued use.

    Read more about the use of amitriptyline to prevent tension-type headache.

Other medicines for preventing migraines

Other medicines are occasionally used to prevent migraines. Treatment can be complicated and is often best managed by a specialist (neurologist).

  • Antiepileptic medicines, especially sodium valproate (Epilim , Valpro) and topiramate (Epiramax, Tamate)

    These medicines are effective at preventing migraine but have significant side effects that can limit their use. They can cause sleepiness or difficulty concentrating. Valproate causes weight gain whereas people on topiramate may lose weight. These medicines can also interact with other medicines and are not safe to use in pregnancy.

  • Pizotifen (Sandomigran)

    One of the original medicines marketed for the prevention of migraine, pizotifen is rarely used these days. It is not very effective and few people can tolerate its side effects, including weight gain, drowsiness and dizziness.

  • Methysergide (Deseril)

    The most effective of all the migraine prevention medicines, methysergide is now only reserved for severe and resistant cases because of its serious potential side effects. It can be only taken for a maximum 6 months at a time because of the risk of scarring of tissues in the chest and abdomen. This can cause damage to heart valves and retroperitoneal fibrosis, a rare disorder in which the ureters (tubes that carry urine from the kidneys to the bladder) can become blocked by fibrous tissue in the area behind the stomach and intestines. Kidney failure can occur. This medicine should therefore only be used under specialist supervision, where regular heart and abdomen ultrasounds can be used to detect problems before they become serious.

  • Botulinum toxin

    Some people who experiences headaches on at least 15 days per month may benefit from preventive treatment with botulinum toxin (botox); however, this treatment is not currently subsidised on the PBS and therefore may prove expensive.

  • National Prescribing Service Limited . Headache and migraine. NPS News 38. Sydney: NPS, 2005. www.nps.org.au/health_professionals/publications/nps_news/archive/NPS_News_38
  • British Association for the Study of Headache. Guidelines for all health professionals in the diagnosis and management of migraine, tension-type-type headache, cluster headache and medication overuse headache. Hull: BASH, 2010. www.bash.org.uk (accessed 13 December 2011)
  • Neurology Writing Group. Therapeutic Guidelines: Neurology, Version 4 Updated November 2011 [eTG complete CD-ROM]. Melbourne: Therapeutic Guidelines Ltd, 2011.
  • Rossi S, ed. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd, 2012.
  • Evers S, Afra J, Frese A, et al. EFNS guideline on the drug treatment of migraine - a revised report of an EFNS task force. European Journal of Neurology 2009;16:968-81. www.efns.org/fileadmin/user_upload/CME_articles/CME_article_2009_September.pdf