Preventive Treatments

The decision to take preventive treatment is yours. Discuss the pros and cons with your physician or nurse practitioner. Establishing clear expectations of your treatment goals and having a plan you’re comfortable with is key.  

There are several types of preventive medications and they act through different mechanisms in the brain to increase the migraine threshold (the limit your brain has for migraine occurrence) and make the brain less susceptible to triggers that result in a migraine attack. 

Older migraine preventives have not been designed specifically for migraine. Often, their effect on migraine has been observed by people who were taking them for other reasons. Remember that medications may have different effects on the brain and body. For example, blood pressure drugs also have effects on brain networks.  You are not being prescribed these medications because your healthcare professional thinks that depression or blood pressure are the cause of your migraine.

Like any medication, preventive medications have possible side effects and risks. Some people should not take some of these medications for medical reasons, it is up to your doctor or nurse practitioner to check which treatment is best for you.

Track your baseline migraine frequency with a headache diary! Improvement can be seen in reduced frequency and severity of attacks, better response to acute treatments, and overall quality of life.

Ultimately, the goal is to decrease the impact of migraine on your life. There are two types of improvement: on frequency and on severity.

• A preventive treatment decreases migraine frequency by 50% in 50% of patients who try it. Some people may have a “super response” to some medications (75% better).
• Severity can also decrease: you may have less nausea, your acute treatments may work better, you may be able to miss work or activities less often. Often if migraine frequency remains the same, but the severity decreases, this is enough reason to continue the preventive treatment.

• Less sensitivity to triggers
• Better effect of acute medications
• More ability to plan activities
• Better mood and sleep

There is no one-size-fits-all solution. People with migraine have different brains and different bodies. At the present time, no one can predict who will improve with a certain medication or not. Trying different options is key.

1. First time using preventive medication, start with a blood pressure lowering medications – Propranolol, Nadolol or Metoprolol OR an antidepressant – Amitriptyline
2. If people desire low side effects: blood pressure medication – Candesartan or Lisinopril OR herbs/vitamins – Magnesium, Riboflavin or Co-enzyme Q10
3. People who are overweight: Topiramate
4. People with high blood pressure: Propranolol, Nadolol, Metoprolol, Candesartan or Lisinopril
5. People with depression/anxiety: Antidepressants – Amitriptyline, Nortriptyline or Venlafaxine.  People with depression should not take flunarizine
6. People with migraine not well controlled on 1 medication alone: combination therapy with 2 different drugs
7. Migraine during pregnancy: avoid drugs if possible. If not, consider – Magnesium, Propranolol, Metoprolol, Amitriptyline or Nortriptyline. Please note, Valproic acid and Topiramate should be avoided in pregnancy due to the known risks associated with the fetus.
8. Migraine during breast-feeding: avoid drugs if possible. If not, consider – Magnesium, Propranolol, Nadolol, Metoprolol, Amitriptyline, or Nortriptyline.
9. People with seizures: try one of the migraine prophylactics that are also anti-seizure drugs.
10. People with asthma: avoid beta-blockers

Side effects vary by medication and are often mild and temporary. Not everyone will experience side effects. If the effects are mild, like dry mouth or minimal sedation, and your migraine has improved, it may be worthwhile staying on the medication.  In consultation with your doctor, it is a personal decision to weigh the pros and cons.

It is important to note that side effects often occur quickly but it may take longer to see a benefit from the preventive medication.

They differ depending on the medication. For more information, please see our post on doses, side effects, and contradictions.

Some preventives are associated with weight gain, others with weight loss, and many are weight neutral. If you do start a preventive that can cause weight gain, monitor your weight and diet. 

Preventive medications need to be taken at effective doses for several months. One month is never enough to make a decision.

• For oral preventives (excluding gepants), it usually takes a month to titrate up on the dose and 2-3 months on the effective dose to see full benefit.
• For Botox, at least 2 cycles (3 months apart) is recommended.
• For CGRP antibodies, a trial period can be between 3 and 6 months (even though some people improve right away).

Migraine attacks often occur in cycles, with periods of increased frequency followed by times of relative calm. Various factors, such as less sleep, more stress, new medications, or hormonal changes, can trigger these episodes, but sometimes the reasons are unclear. If your migraine frequency rises, do not stop your preventive medication, assuming it has lost its effectiveness, as this can worsen your condition. Instead, keep a diary to identify potential triggers or aggravating factors. It’s a common mistake for people with migraine to stop their preventive treatment out of frustration, especially during difficult periods. If the increased frequency persists for many weeks, consult your physician, as it may be more effective to adjust your dosage rather than discontinuing it.

Preventive agents are not necessarily used for many years. After 8-12 months of successful treatment, one could slowly taper and try to discontinue the preventive medication. If migraine attacks increase, then the treatment is still needed and may be continued. 

Long term treatment may be required for some people. Research shows that continuing with a preventive increases the chances of remaining stable in the long term. If something works, keep doing it!

Preventive medications do not cause addiction (opioids and cannabinoids do). If effective, they are continued for at least a year before considering a dose reduction. Always consult your healthcare provider before stopping any medication. If you decide to taper down, do it very slowly. Never stop preventive medications abruptly, as this could trigger intense migraine attacks.

Here are five situations where migraine can be drastically improved and preventive medications might be stopped: 

• Retirement 
• Menopause (especially in women with hormone-sensitive migraines)
• Resolution of a major personal stressor or conflict 
• Successful management of a major medical issue (sleep apnea is a common example)
• Radical and sustained changes in your lifestyle 

Using migraine preventives can lead to a virtuous circle that may allow you to stop the drug. It’s easier to adopt a healthy, migraine-friendly lifestyle when one is feeling better and life becomes more predictable. Anxiety and depression may improve as you gain some control over your life. Migraine frequency may drop even further, and the preventive might be stopped.  

That may happen. But before concluding that your preventive does not work, consider the following possibilities.

• Migraine tends to fluctuate spontaneously. Maybe this is just a bad phase.
• Is the deterioration caused by a factor that can be addressed, like a major change in stress levels or lifestyle?
• Is it possible that you have reset your normal? It is common that as people get better, they may feel that 6 days of migraine symptoms is bad. However, when they were having 12 days per month, 6 was actually quite good.

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