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Migraine Prophylaxis

Migraine Preventive Treatment – Life Style – Triggers – Supplements – Nutrition

Migraine Prophylaxis

Migraine prophylaxis goal is a reduction of severity and frequency of migraine attacks as well as an improvement of headache response to abortive treatment. Successful treatment normalizes quality of life and reduces disability.

This approach is reserved for severe, frequent, or poorly responding to abortive treatment migraine. The drugs employed in migraine prophylaxis belong to different classes. None of the modern prophylactic agents was originally designed for this purpose.

Mechanisms responsible for migraine preventive effects remain poorly understood. Whether prophylactic treatment prevents development of migraine complications or improves its prognosis remains unclear.

Migraine prevention remains underutilized. Based on recent estimates, at least 40% of migraineurs have to be at least offered this treatment option. In reality, only 12% of all migraineurs are getting some form of prevention. Here are the most common medications for migraine prevention.

Propranolol (Inderal)

Propranolol belongs to the group of beta-blockers. This group of medications is intended for heart disease and blood pressure management. From time to time, other medications from this group are claimed to be effective for migraine prevention but I don’t buy it.

Propranolol is my favorite initial medication. It is well tolerated and statistically effective in about 50% of migraineurs.

The major contraindications are insulin dependent diabetes and active asthma. Relative limitations are slow heart rate and migraine with aura. There is no proof that Propranolol may cause a stroke if used for migraine with aura and the concern is mostly theoretical.

Propranolol is available in extended release form (taken once a day) and immediate release form, which has to be taken 2 to 3 times per day. I use almost exclusively extended release form for practical reasons.

Topiramate (Topamax)

Topiramate was originally unsuccessfully tried for type II diabetes treatment and was eventually marketed for epilepsy. It is currently widely used for migraine prevention. Multiple trials prove its dose dependent effect. The dose of 100 mg per day is equal in effect to Propranolol (50% have at least 50% improvement in headaches). The dose of 50 mg is effective in about 40%. The dose of 200 mg per day offers some additional benefit (65%). High Topiramate doses are predictably poorly tolerated.

The most common adverse effects are tingling sensation, often all over the body (up to 50%), fatigue, and decreased concentration. Many patients do not want to trade their headache for these side effects.

Topiramate increases the likelihood of kidney stones about threefold. Although rear, an acute glaucoma (increased pressure inside the eye) may develop. Should any blurred vision or eye pain develop, it is recommended to stop it ASAP (upon discretion of your doctor). Topamax leads decreased sweat secretion and may precipitate a heat shock during hot weather.

Most of migraine preventive drugs have a weight gain as a side effect. Topiramate is actually responsible for weight loss after a long term use.

Valproate (Depakote)

Valproate has been known for its efficacy in migraine prophylaxis for years. Valproate is an anticonvilsant (anti-epileptic drug). Doses for migraine management are usually lower than for epilepsy treatment.

Tolerated well. No sedation. Major common side effect is nausea. Valproate may cause birth defects and is not recommended for young females. Possible weight gain.

Although relatively rear it may cause hair loss, hepatitis, pancreatitis and low blood cell count. Regular blood tests are recommended especially during the first months of treatment.

Amitriptyline (Elavil)

Amitriptyline is a stone-age old antidepressant, which is rarely utilized in depression management nowadays. It remains a valuable agent in pain management up until now.

Multiple antidepressants were tried for migraine prophylaxis. Amitriptyline has been the only antidepressant, which has been consistently shown to be effective. For migraine it works in low doses taken once at night.

The most common side effects are dry mouth, constipation, dizziness, blurred vision, palpitations, mental confusion, low blood pressure, carbohydrate cravings with subsequent weight gain.

It is not recommended in older people.

Petasites (Butterbur)

Butterbur root extract appears to be effective for migraine prevention.

Butterbur is a toxic plant. Birth defects, liver damage and carcinogenesis are the major concerns.

Riboflavin (Vitamin B2)

Riboflavin is an option for those who are looking for more “natural” treatment. I personally see nothing natural in taking vitamin mega-doses.

This agent requires patience. It takes up to three months to work. The effective dose (400 mg per day) is 40 times of normal physiological dose.

It may cause light sensitivity. Wearing sun glasses in a bright sun is recommended. Other potential side effects are tingling and urine discoloration.

In one study 59% o0f patients reported improvement in headache frequency and severity. None of my patients has ever reported any headache improvement on high dose Riboflavin.

Coenzyme Q10
Co Q10 taken three times a day is reported to decrease the headache frequency in about half of migraineurs.
Botox injections

Botulinum toxin made an impressive run from being a feared food poison of the past to a revolutionary drug of the present. Botulinum toxin did make revolution in dystonia and spasticity treatment.

I, personally, do not feel thrilled about Botox use in migraine. In spite of popularity, the effectiveness of this treatment remains questionable. Clinical trials are inconclusive.


Acupuncture is a viable option for any pain syndrome, migraine included. No superiority to other treatment options; cumbersome and hard to use long term.

Considering acupuncture acts upon the same brain receptors as narcotics and narcotics don’t work well on migraine, I am not optimistic about this approach.

Medications: Brand vs. Generic vs. Supplements

Brand Medications ARE BETTER. They have higher quality standards for the amount of both active and inactive ingredients. They are more predictable. Generic drugs are allowed to have +/- 20% bioavailability of the drug compared to the brand, according to the current regulations.

Let’s say, you are taking Inderal LA 80mg once a day. If you change brand to generic form (Propranolol XR 80 mg), the amount your body will actually get is going to be equivalent the dose ranging from 65 mg to 95 mg. For the extended release (XR) forms it is even more complicated. If the active ingredient is not released steadily, you can get either too much or too little of it at some point of the day.

Genetic medications may stop working or produce new side effects after getting a new refill. The same generic medication is often made by different companies. Getting the drug from the previous manufacturer sometimes solves the problem.

Supplements are even less predictable. If Melatonin does not work for cluster headache, the next step is a trial of the same supplement from a different supplier.

Life Style, Triggers and Nutrition in Migraine

Life style modifications and nutrition have very limited value in migraine management. It is all about eliminating the migraine triggers. The importance of triggers in migraine is generally overstated. Triggers provoke migraine attacks only when they are meant to happen.

In some people, migraine can be triggered by insufficient or excessive sleep, long breaks between meals, some types of food ???, or strong emotions (no matter positive or negative).

Even if you place some migraine sufferer in a bubble and eliminate all the possible triggers, headache attacks will not stop. They will be just somewhat less frequent. Besides, no one wants to live in a bubble. If you know your triggers and you are able to avoid them – do it.

Moderate physical activity may decrease headache frequency. Strenuous exercise may provoke migraine attacks.

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