Learn all about migraine prevention and how to create a preventive strategy with your provider
Between the pain of an attack to the disruption of plans, migraine can really throw a wrench into the works. While there is no cure for migraine, management and prevention are your best friends. When migraine attacks increase in frequency or severity to the point that they disrupt your ability to work or participate in your usual activities, it could be time to consider a preventive migraine strategy.
What is migraine prevention?
Instead of treating migraine attacks once they begin, migraine prevention emphasizes treatment methods and strategies that can reduce the frequency, severity, and duration of migraine attacks. They can also make your acute (or as-needed) treatments work better.
Migraine prevention can include prescription and non-prescription medication regimens; natural supplements, vitamins or minerals; lifestyle changes, or a combination of things. It often takes trial and error plus consideration of any other medical conditions you have to figure out what is best for your specific situation.
Though it may feel frustrating to use a trial and error method to find the right preventive migraine plan for you, keep in mind that not all people living with migraine are the same. Different people have different sensitivities to side effects, and your individual situation is important when deciding on the right medications.
Ideally, a preventive migraine strategy should involve both the patient and the caregiver. Work with your provider to find the right strategy for you based on your migraine symptoms, any other health conditions you have and medications you’ve already tried, plus any side effects you’ve experienced.
What are the benefits of migraine prevention?
Acute migraine treatments can lead to medication overuse headache (previously known as rebound headache) if used too frequently. Instead, a preventive strategy focuses on preventing migraine; reducing the frequency, severity, or intensity of attacks; and making them more responsive to acute medications when needed.
Preventive treatments can also be used to help with other health issues, such as high blood pressure, depression, trouble sleeping and more.
Other benefits to a successful migraine prevention plan include reducing the level of disability, reducing any excessive use of acute treatments and maintaining lower cost of care for migraine treatments.
Who is migraine prevention for?
A preventive migraine strategy is for anyone that is unable to participate in their usual activities or work on a regular basis due to migraine. If the frequency, severity or intensity of your migraine attacks are worsening, then it’s time to consider a preventive strategy.
Types of preventive migraine treatment
Lifestyle changes are one way to prevent migraine or reduce the frequency or severity of attacks. The SEEDS model explained in this blog is a simple mnemonic device that can help you remember to practice self-care basics that can help ward off or reduce the frequency of migraine attacks.
When it comes to other migraine treatment methods, there are eight main types: high blood pressure medications, anti-seizure medications (anticonvulsants), anti-calcitonin gene-related peptides (CGRP) therapies, antidepressants, natural supplements, miscellaneous medications, neuromodulation devices, and neurotoxins.
Some medicines used to help prevent migraine had different original intended purposes. These include medications used to treat high blood pressure, seizures, and anxiety/depression. These have all been tested and proven beneficial in migraine clinical trials. Often the doses used for migraine are very small compared to the original intended purpose. Some vitamins and minerals have also been shown to be helpful in migraine. Neurotoxins have also been tested and shown to be helpful. Neuromodulation devices and CGRP-based therapies were developed with migraine as their main target.
Along with the various types of medication choices, there are several different approaches to a preventive strategy using medication. Using one medication, titrated to the ideal dose, is called monotherapy.
Another approach is using two drugs—commonly from two different classes—in less than maximal doses. Doctors do this so that the medications complement each other but also reduce unwanted side effects by using less than maximum doses for each medication. Using two or more medications at once is called polytherapy.
When using more than one medication at a time, it’s important to make sure that they won’t interact negatively with one another. Our FAQ on migraine drug interactions explains more about common migraine medication interactions to be aware of, and your doctor will know best as well.
When there is an inadequate response to one or two drugs, sometimes three or more drugs are used in varying doses until the desired effect is achieved. Just remember that you are an active participant in this process. Work alongside your healthcare providers to communicate your preferences, along with what is and isn’t working for you.
It may take two to three months before you notice a decrease in the frequency or severity of attacks even after reaching “the beneficial dose.” You may reqruite treatment for six to twelve months or longer. But it’s important to stay optimistic, monitor your migraine attacks and stay the course of treatment.
Another aspect to consider when working with your provider to create a preventive migraine strategy is to recognize that you may have more than one medical concern that can be treated simultaneously. Feel free to use medication therapy strategically to address more than one medical concern at once. For example, if you have depression and migraine, it may make sense to trial an antidepressant that has been shown to be effective for preventing migraine as well. If you have high blood pressure and migraine, then one of the drugs used for hypertension and migraine may be a better fit for you.
Now let’s review a list of commonly used preventive medications as well as which medication classes they’re in. Use this list to see which class of medications may make the most sense for you, while keeping an eye on possible side effects to be aware of. Below the table you’ll find a more comprehensive explanation of each medication category.
Commonly used preventive treatments
|Type of Medications||Medication Class||Generic Name||Side Effects|
|Anti-CGRP monoclonal antibodies||CGRP inhibitors||Erenumab
|Injection site pain and swelling
|Blood pressure medications||Beta-blockers||Atenolol
|Low blood pressure
Low heart rate
Angiotensin receptor blocker
Low blood pressure
|Selective Serotonin/Norepinephrine Reuptake Inhibitors (SNRI)||Duloxetine
|Weight gain or loss
|Anti-seizure medications||Divalproex sodium
|Weight gain or loss
|Vitamins, minerals and supplements||Magnesium salts||Magnesium oxide, magnesium diglycinate, magnesium chloride slow release||Diarrhea|
|Vitamins||Riboflavin (Vitamin B2)
|Herbals||Mig-99 (Feverfew)||Burping, GI|
|Neuromodulation Devices||Transcutaneous Supraorbital Neurostimulator
Transcutaneous Vagus Nerve Stimulator
Non-invasive multi-channel brain neuromodulation system
Remote electrical neuromodulation (REN)
Single pulse transcranial magnetic stimulation (sTMS)
Flu-like symptoms (rare)
Learn more about each class of migraine prevention
Anti-calcitonin gene-related peptide (CGRP) therapies
Anti-CGRP therapies are injections designed specifically for treating and preventing migraine. This article answers common questions about anti-CGRP therapies, which are designed to target CGRP, a protein involved in generating the head pain associated with migraine. Anti-CGRP therapies work by blocking CGRP from attaching to its receptor, thereby blocking the pain signal. In comparison with traditional medications, anti-CGRPs typically have fewer side effects.
Blood pressure medications
These are old standbys in migraine prevention. The evidence favors the beta-blockers metoprolol, propranolol and timolol, followed by atenolol and nadolol. Propranolol and timolol have U.S. Food and Drug Administration (FDA) approval for migraine prevention; the others do not. Side effects include low blood pressure, low heart rate, fatigue, depression, nausea, insomnia and dizziness.
This group of medications can be equally as effective as beta blockers. Divalproex sodium and sodium valproate is a long-standing and effective preventive agent. Generally, it is well tolerated too, but can be associated with weight gain and polycystic ovaries, and should be avoided by those with liver disease. Topiramate is another effective preventive medication. While it can result in tingling, word finding problems and memory issues, it can also cause appetite suppression. Both valproate and topiramate are FDA-approved for migraine prevention. Neither should be used in women who are not using birth control, as they can cause birth defects. Other commonly used anti-seizure medications for prevention, such as gabapentin and lamotrigine, are not FDA approved.
Amitriptyline is an old, inexpensive medication that effectively prevents episodic migraine. While it can help with sleep and mood, it can result in weight gain, sedation and dry mouth. A newer antidepressant that made it to the preventive list is venlafaxine, which helps with mood and does not result in weight gain. You can take these in the morning and it can be energizing, so it does not help people fall asleep. Selective serotonin reuptake inhibitors, such as fluoxetine (Prozac), sertraline (Zoloft) and paroxetine (Paxil) work well for depression and anxiety, but lack strong evidence supporting effectiveness as migraine preventives.
Nutritional supplements, vitamins and minerals
The supplement group is usually well tolerated by most people, although the effectiveness may not match stronger prescription counterparts. Riboflavin, magnesium and MIG-99 (feverfew) are probably effective, and CoQ10 is possibly effective. Learn more about nutraceuticals here.
Neuromodulation devices use electrical currents or magnets to adjust or change activity that occurs in the brain. Some of these devices can stop migraine attacks that are already underway, while others have preventative uses. Some devices are cleared for both acute and preventive treatment. A few are even cleared for use in adolescents. Learn more about the four FDA-approved neuromodulation devices on the market.
OnabotulinumtoxinA, also known as Botox®, is a form of botulinum toxin, a neurotoxin. A neurotoxin is a poison that acts on the nervous system. When purified and used in small doses, OnabotulinumtoxinA temporarily prevents muscle contractions in the muscle you inject it in. Even though the injection goes into the muscle, it is believed that onabotulinumtoxinA blocks pain signals in nerves in the head, neck and shoulders. Its effect lasts up to 3 months. In October 2010, the FDA approved OnabotulinumtoxinA injection therapy for the preventive treatment of chronic migraine, which is defined as 15 or more headache days per month. This article talks more in length about Botox injections used for migraine.
The American Migraine Foundation is committed to improving the lives of those living with this debilitating disease. For more of the latest news and information on migraine, visit the AMF Resource Library. For help finding a healthcare provider, check out our Find a Doctor tool. Together, we are as relentless as migraine.
Reviewed for accuracy by the American Migraine Foundation’s subject matter experts, headache specialists and medical advisers with deep knowledge and training in headache medicine. Click here to read about our editorial board members.