«What’s the best preventive for migraine»? 

Sadly, there is no answer to this question. 

Many different approaches exist, and it is not possible to predict which one will work for one person in particular. 

For each option, there are people who do not improve (non-responders), people who improve partially (30%, 50%, partial responders), and people who improve a lot (75%, super-responders). 

The same applies to side effects. They cannot be predicted, some people have them and others don’t.  

So how do I decide which preventive to try? 

  • Your physician must check which preventive you cannot use for medical reasons (contra-indication). Example: people with asthma should not use beta-blockers. 
  • See if the side effect profile is acceptable for you. Example: if you are overweight, a medication causing weight gain is not ideal. If you have insomnia, a medication causing somnolence taken at bedtime could be good. 
  • Check your insurance coverage. Some drugs can be used only as second or third line, after trying cheaper drugs. Example: In Canada, Botox and CGRP antibodies will not be covered if you have not tried 2 other preventives. 

Table of Migraine Preventives

** This table is an overview of options. A more detailed table is also available with doses, contra-indications and common side effects. 

ClassExamples Generic (brand name)How does it work
Anti-hypertensiveCandesartan (Atacand)
Propranolol (Inderal)
Nadolol (Corgard) 
Verapamil (Isoptin)
Unclear. Some decrease the electrical hyperexcitability of the brain.
Anti-depressantAmitriptyline (Elavil)
Nortriptyline (Aventyl)
Venlafaxine (Effexor)
Modulate pain networks (serotonin, adrenalin, noradrenalin)
Anti-seizureTopiramate (Topamax)
Gabapentin (Neurontin)
Decrease the hyperexcitability of the brain neurons
CGRP antibodiesErenumab (Aimovig)
Galcanezumab  (Emgality) 
Fremanezumab (Ajovy) 
Block CGRP that plays a role in the migraine cascade Designed for migraine
SupplementsMagnesium
Vitamine B2
Coenzyme Q10
Feverfew
** Petasites or butterbur not used anymore for liver toxicity concerns
Vitamin D
May influence the energy metabolism of the brain and stabilize neurons
Injectable toxinsOnabotulinum toxin type A (Botox) Modifies the function of sensory nerves, and decreases the input to the brain
NeuromodulationTranscutaneous stimulation (Cefaly)
Vagus nerve stimulation (Gamma Core) 
Transcranial Magnetic Sitmulation (eNEura, not available in Canada) 
Influences the pain networks with electrical currents


Table: Therapies for which there is no strong evidence that it works more than placebo (more research needed OR strong placebo effect suspected). 

CategoryExamplesHypothetical mechanism (NOT proven)
InjectionsAcupuncture

Nerve blocks

Daith piercing

Sphenopalatine Ganglion (SPG) Blocks
Influence of the energy meridiansMuscle and nerve modulation

Blocking sensory inputs to the brain

Modulation of the vagus nerve function (not proven)

Modulate the nerve networks passing in this ganglion 
CannabinoidsCannabis, CBD oil (many available with different THC, CBD content and ratios)The cannabinoid system influences virtually every system in the brain, including the pain network but also others
SurgeryDecompression of nerves 
Neurostimulation with implants
Relieve the pressure on nervesModulate the pain system
OpioidsMorphine and othersShould NOT be used for migraine prevention due to risksAct on opioid receptors in the brain (mu, kappa, delta receptors) 

A warning: should any drug that treats epilepsy, hypertension or depression be used for migraine «just in case it works»? 

Some tables online list many other drugs, especially anti-hypertensives and anti-depressants, that some physicians may use but have not been studied specifically for migraine. You should be careful. These very long lists are not medically recommended. 

Now, read about a few tips to try preventives! 

See this post

REFERENCES

Pringsheim T, Davenport W, Mackie G, Worthington I, Aube M, Christie SN, et al. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012;39(2 Suppl 2):S1-59.

Rajapakse T, Pringsheim T. Nutraceuticals in Migraine: A Summary of Existing Guidelines for Use. Headache. 2016;56(4):808-16.

McGeeney BE. Cannabinoids and hallucinogens for headache. Headache. 2013;53(3):447-58.

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