When to Start Preventive Therapy for Migraine? 2023
When to Start Preventive Therapy for Migraine?
Preventive therapy may be called daily treatment or prophylactic treatment. It means that the doctor intends his patient to take a daily drug to reduce the intensity and frequency of the patient’s migraine headaches.
With the advent of new anti-CGRP drugs, the patient may need to self-inject subcutaneously or visit an infusion center for IV treatment every month.
The patient should understand that they are in a drug trial and to log their headaches in a diary and use the drug for 6-8 weeks to judge results and improvement, or no response for their migraine headaches before giving up.
To get a good start read my article, “What is migraine?” on my website, www.doctormigraine.com.
Read my Mini Book on Migraine Here.
This is an article by Britt Talley Daniel MD, retired member of the American Academy of Neurology, the American Headache Society, migraine textbook author, and blogger.
Preventive therapy should be considered for patients who:
Experience 3-4 or more migraines per month
Have Chronic Migraine-defined as 15 headache days per month, 8 of which have migraine features
Present with medication overuse headache
Who prefer this type of treatment?
Have significant pain that hampers their life
Take a lot of over the counter, narcotic, opioid or barbiturate pain killers
Don’t get enough relief from the acute treatment medication they are currently taking
Have side effects from drugs used for acute therapy
Related questions:
1. Preventive treatment might not be an option for patients who:
Can control their headaches with anti-inflammatory drugs (NSAIDS) like naproxen or ibuprofen
Have other health conditions that don’t allow taking preventive drugs
Might already be taking drugs that wouldn’t mix well with any proposed preventive medication they might take
Prefer treatments that don’t involve taking medications
Can get relief from exercise relaxation therapy, stress-management, or biofeedback
Prefer a medical device called Cefaly, which is an FDA approved treatment for migraine prevention. It is worn on the head, delivers electrical impulses, and is used once a day for 20 minutes.
Are pregnant, as migraine usually improves in the 2nd or 3rd trimesters of migraine and all medications should be limited for pregnant patients.
2. What are the American Academy of Neurology and American Headache Society recommendations for preventive drugs?
Level A drugs, that is those which have been established as effective, are:
Divalproex sodium, sodium valproate 400-1000 mg/day
Topamax (topiramate), short acting ,or Trokendia XR, Qudexy XR, long acting 25-200 mg/day
Frovatriptan (long acting triptan--26 hours) for menstrually related migraine short term 2.5 mg/day
Onabotulinumtoxin A (Botox)--physician injects onabotulinumtoxin A into the muscles of the forehead and neck. When effective, the treatment is repeated every 3 months. Indicated by the FDA for persons with Chronic Migraine (15 headache days/month, 8 of which are like migraine).
Botox has been found to be only modestly effective for preventing migraines in the most frequent suffers. Botox prevented 1.8 headaches a month more than placebo.
Betablockers
Metoprolol 47.5-200 mg/day
propranolol 120-240 mg/day
Timolol 10-15 mg bid
Level B drugs, those which are “probably effective.”
Amitriptyline 25-150 mg/day
nortriptyline 25-50 mg/day
venlafaxine 150 mg extended release/day
Level C drugs, thought to be “possibly effective.”
ACE inhibitors (lisinopril) 10-20 mg/day
angiotensin receptor blockers (candesartan) 16 mg/day
alpha-agonists (clonidine) 0.75-0.15 mg/day; patch formulations also studied
carbamazepine 600 mg/day
Cyproheptadine 4 mg/day
Atenolol 100 mg/day
Guanfacine 0.5-1 mg/day
3 Special considerations
All of the listed drugs above for prevention may reduce headache significantly. However, there are special considerations for patients with multiple medical problems using these drugs
Patients who are anxious and can’t sleep or have depression may be given amitriptyline or nortriptyline. Amitriptyline is also the go to drug for patients who have limited funds or no insurance drug coverage since it is so cheap, often just 3-4 dollars a month.
Persons who have epilepsy and migraine and overweight should be offered topiramate, but this drug shouldn’t be given to patients with a history of kidney stones.
Patients with tremor, hypertension, or migraine may be given a beta blocker which may treat all three conditions.
Thinking this way, the doctor and the patient may get a double treatment effect from a single preventive medication.
Also there is no endorsement by the American Academy of Neurology or the American Headache Society on the new CGRP drugs—Aimovig, Ajovy, Emgality, or Vyepti for migraine prevention, but it’s well known that these new drugs work better than the old time preventive drugs listed above.
Stay tuned for new data on these CGRP drugs for preventing migraine. For now, see my articles on these drugs at my website, www.doctormigraine.com:
Aimovig-Read “Vascular Safety of Aimovig (erenumab) For Migraine Prevention.”
Ajovy-Read “Ajovy for Migraines.”
Emgality-”Emgality for Migraine and Cluster Headache.”
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Check out my Big Book on Migraine Here.
All the best.
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Britt Talley Daniel MD