Who should take a medicine to prevent migraine attacks?
There is no definite rule. For example, you may wish to consider this option if you have:
- More than two migraine attacks per month that cause significant disruption to your life.
- Less frequent, but severe migraine attacks.
- The need to use a lot of painkillers or triptan medicines to treat migraine attacks.
- Painkillers or triptans for migraine attacks not working very well, or you being unable to take them because of side-effects or other problems.
- Migraine attacks, which are suspected of causing medication-overuse headache – see below.
Before embarking on preventative treatment, it is probably best to keep a migraine diary for a few months to assess:
- How often and how bad your migraine attacks are.
- Your current use of medication to treat the migraine attacks.
This may help you to decide if preventative treatment is worth a try, and also to help assess if you may have medication overuse headache. See separate leaflet called ‘Migraine – Triggers and Diary’ which includes a migraine diary that you may like to print out and use.
What is medication overuse headache?
Medication overuse headache is caused by taking painkillers or triptan medicines too often for tension-type headaches or migraine attacks. It is a common cause of headaches that occur daily, or on most days. About 1 in 50 people develops this problem at some time in their life.
The following is a typical case …
You may have a bad spell of tension-type headaches or migraine attacks, perhaps during a time of stress. You take painkillers or a triptan more often than usual. You continue doing this for a while. Therefore, your body becomes used to the painkillers or triptan. A rebound or withdrawal headache then develops if you do not take a painkiller or triptan within a day or so of the last dose. You think this is just another tension-type headache or migraine attack, and so you take a further dose of painkiller or triptan. When the effect of each dose wears off, a further withdrawal headache develops, and so on. A vicious circle develops. In time, you may have headaches on most days, or on every day, and you end up taking painkillers or a triptan every day, or on most days.
So, some people who may think they are getting frequent migraine attacks are in fact getting medication-overuse headache. If you use painkillers or a triptan medicine on more than two days per week on a regular basis, you are at risk of developing medication-overuse headache.
You should talk to your doctor if you suspect that you may have medication-overuse headache. It is essential to rule this out before preventative treatment for migraine is started. There is a separate leaflet called ‘Headache – Medication Overuse’ which has further details.
Which medicines are used to prevent migraine attacks?
These include propranolol, metoprolol, timolol and atenolol. They are commonly used to treat conditions such as angina and high blood pressure. It was first noticed by chance that some people who were treated for angina, who also had migraine, found that their migraine attacks lessened when on propranolol. It is not clear how they work to prevent migraine. However, betablockers are now a common treatment for migraine. A low dose may work, but the dose can be increased if necessary. Some people cannot take betablockers. For example, some people with asthma, chronic obstructive pulmonary diseases, peripheral vascular disease, or heart failure.
Medicines called sodium valproate and topiramate are sometimes used. These are classed as anticonvulsants, and are usually used to prevent seizures of epilepsy. However, it was found that they can also prevent migraine attacks.
Amitriptyline is classed as an antidepressant. However, it has an antimigraine action separate to its antidepressant effect. It is not clear how it works for migraine. A low dose is started at first, and can be increased if necessary. Some people cannot take amitriptyline. For example, people who have had a myocardial infarction (heart attack), or have ischaemic heart disease, arrhythmia, or epilepsy. Note: strictly speaking, amitriptyline is not licensed for preventing migraine. However, in practice, it is commonly used, and many doctors are happy to prescribe it for this purpose.
This medicine is classed as a calcium-channel blocker. It is used quite a lot in many countries as a medicine to prevent migraine. However, flunarizine is not marketed and is not licensed in the UK. Despite this, it is sometimes specially imported from abroad under the direction of a headache specialist when it is considered worthwhile to try.
Various other medicines have been used for the prevention of migraine attacks. Most have limited evidence regarding their effectiveness or have potentially serious side-effects. However, if all else has failed, a specialist may suggest that you try out one of these. They include: pizotifen, methysergide, gabapentin, calcium-channel blockers, lisinopril, and selective serotonin reuptake inhibitors (SSRIs).
Some points about medicines to prevent migraine attacks
- You need to take the medicine every day.
- It is unlikely to stop migraine attacks completely. However, the number and severity of attacks are often much reduced by a preventative medicine. It is useful if you keep a migraine diary to monitor how well a medicine is working.
- It may take 1-3 months for maximum benefit. Therefore, if it does not seem to work at first, do persevere for a while before giving up.
- It is common practice to take one of these medicines for 4-6 months. After this, it is common to stop it to see if it is still needed. It can be restarted again if necessary.
- If a migraine attack occurs, you can still take painkillers or a triptan in addition to the preventative medicine.
- It is worth trying a different medicine if the first one you try does not help.
- Read the leaflet in the medicine packet for a list of cautions and possible side-effects.
Medicines plus behavioural therapy
An interesting research study published in 2010 compared two groups of people who had frequent migraines. One group took a betablocker medicine alone. Another group took a betablocker but also had a course of behavioural migraine management (BMM). BMM included education about migraine, helping to identify and manage migraine triggers, relaxation techniques and stress management. After a number of months the group of people who took the betablocker plus BMM had, on average, significantly fewer migraines compared with the group who took betablockers alone. Further research is needed to confirm this and to look at BMM combined with other medicines to prevent migraine.
Botulinum toxin injections (Botox®) to prevent migraine
In July 2010 the Medicines and Healthcare products Regulatory Agency (MHRA) licensed the use of botulinum toxin injections for the prevention of migraine. This decision was based on research studies that seemed to show it to be an effective treatment at reducing the number of migraine attacks. To be eligible for this treatment you must have headaches for 15 or more days per month, with migraine headaches being on at least eight of these days.
Treatment in the research trials consisted of up to five courses of treatment with botulinum toxin injections every 12 weeks. The injections were given into muscles around the head and neck. It is not clear how this treatment may work for migraine. Botulinum toxin relaxes muscles but it may also have some sort of action to block pain signals. The theory is that these actions may have an effect of stopping a migraine headache from being triggered.
However, the use of botulinum toxin injections for migraine is controversial. A paper in the Drug and Therapeutics Bulletin (an influential medical journal) re-analysed the data from the same studies used by the MHRA to make their decision as described above. The authors in the Drug and Therapeutics Bulletin concluded that treatment with botulinum toxin “offers little help in chronic migraine”. Their argument is that they say there were some flaws in the research method and so the research results were not reliable; also, that there is a risk of side-effects, and that the studies also showed that headaches actually got worse in a small number of treated people.
There now seems to be quite a debate as to the use of botulinum toxin. See some reaction to this debate from the Migraine Trust and Migraine Action. Both of these organisations have reports of individuals who seem to have benefited from botulinum toxin injections. So, perhaps further research is needed to clarify the situation.
Note: botulinum toxin injections are also used for cosmetic purposes. For example, as a treatment to smooth out wrinkles. However, for the treatment of migraine the injections need to be in specific sites around the head and neck muscles. Therefore, to prevent migraine attacks, it should only be administered by people trained in its use for this purpose.
Further sources of help and information
References and Disclaimer | Provide feedback
- Migraine, Clinical Knowledge Summaries (October 2010)
- Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache, British Association for the Study of Headache – BASH (2010)
- EFNS guideline on the drug treatment of migraine – revised report of an EFNS task force, European Federation of Neurological Societies (August 2009)
- Diagnosis and management of headache in adults, Scottish Intercollegiate Guidelines Network (SIGN), November 2008
- Dodick DW, Turkel CC, Degryse RE, et al; OnabotulinumtoxinA for Treatment of Chronic Migraine: Pooled Results From the Headache. 2010 Jun;50(6):921-36. Epub 2010 May 7. [abstract]
- Holroyd KA, Cottrell CK, O’Donnell FJ, et al; Effect of preventive (beta blocker) treatment, behavioural migraine management, BMJ. 2010 Sep 29;341:c4871. doi: 10.1136/bmj.c4871. [abstract]
- Dodick DW; Prevention of migraine. BMJ. 2010 Sep 29;341:c5229. doi: 10.1136/bmj.c5229.
- No authors listed; Botox for chronic migraine. Drug Ther Bull. 2011 Feb;49(2):22-4; quiz iii-iv. [abstract]