Long term risks of migraine preventives
Are there risks associated with migraine preventives on the long term?
It is very common for people to stop taking migraine preventives. 80% of people with Chronic Migraine have stopped the preventive medications they were trying within the first year. Lack of effectiveness and side effects are the key reasons. More recent migraine preventives such as Botox, CGRP monoclonal antibodies, and gepants have few side effects and are better tolerated. This helps contribute to better outcomes.
Still, if a medication is effective and well tolerated, then long term effects and risks must be considered. Your healthcare provider should discuss this with you. We do not have long term data on all drugs. Studies were often done on the short term (a few months).
This page does not discuss side effects that may occur on the short term. You can find these in another page (we apologize, there is a lot of information to share!). (See this post)
Table: Long term effect of migraine preventives (alphabetical order)
** Excellent review article by Vanderpluym at al.
| Problem | Ways to prevent it | |
| Amitriptyline (Elavil) | Arythmias Dementia | Check EKG |
| Botulinum toxin (Botox) | No long term toxicity Atrophy of the temporal muscles, usually not a problem Weakness of neck and shoulder can appear if the patient loses weight or muscle mass. | Readjust protocol as needed |
| Candesartan (Atacand) | Used for hypertension on the long term | Monitor blood pressure |
| CGRP antibodies (Aimovig, Ajovy, Emgality, Vyepti) | Long term exposure with erenumab up to 5 years did not reveal toxicity or unexpected health issues. Caution around vascular risks is still in discusion, particularly in those with recent stroke or myocardial infraction or incontrolled cardiovascular disease. These medications haven’t been available long enough for adequate long term data up to 10 years. | More research needed |
| Gepants (Atogepant) | No long term studies available | |
| Propranolol (Inderal) | Increased risk of diabetes Information on long term lacking | Check glucose levels |
| Topiramate (Topamax) | Osteoporosis (depends of duration more than dose) Kidney stones (no surgery) – (1-10%) Kidney stones (asymptomatic) – (20%) | Calcium, vitamin D exercise, less alcohol and stop smoking Hydration Low sodium diet |
| Valproic Acid (Epival, Depakene) | NOT AND IDEAL OPTION: Gastrointestinal (pancreatitis, hepatic failure, non-alcoholic fatty liver) Hematological (leucopenia, thrombocytopenia, pseudolymphoma) Neurological (essential tremor, parkinsonism) Hepatic toxicity Skin and cosmetic (alopecia, hirsutism, acne) Reproductive health (sperm abnormalities, infertility in women, polycystic ovary syndrome) Bone health (osteoporosis, osteopenia) Body weight (weight gain), lipids and atherosclerosis (atherosclerosis, hyperlipidemia, metabolic syndrome) | |
| Venlafaxine (Effexor) | No long term studies available As a note, withdrawing Effexor is sometimes difficult because of the mood symptoms. |
Now I am concerned! What should I do?
The goal of this article is to inform you, not to scare you uselessly. Discuss with your healthcare provider. Taking a medication is always a decision of pros and cons. Medications can improve the quality of life, but people taking them should be aware of possible consequences.
REFERENCES
VanderPluym J, Evans RW, Starling AJ. Long-Term Use and Safety of Migraine Preventive Medications. Headache. 2016;56(8):1335-43.
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