Diagnosing and Treating Migraine : Preventing Migraine

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Why do I need to prevent migraine attacks?

You must prevent migraine attacks because “a headache begets a headache.” Once migraine has been diagnosed, you must start an aggressive treatment program to prevent attacks. Prevention of attacks and stopping attacks quickly is important not just to relieve suffering but also to treat the disease. Without effective treatment, the illness progresses, with attacks becoming more severe and more frequent.

Q:	How do I get started with my migraine treatment?
A:	The first step is accepting the fact that the condition is part of your life. Treatment for migraine is not dependent upon medication only and requires a change in lifestyle. This is not easy. You must take time to learn about the disorder and be prepared to make the changes required to treat it effectively.

How can I make my treatment program successful?

Successful treatment of migraine demands that you make changes to your lifestyle (factors such as diet, exercise, and daily routine) as well as taking medication. Untreated migraine progresses (worsens), causing more disability and interference with work and home life as the years go by. You must make a decision to succeed and persevere with your treatment until you control the migraine attacks. The migraine attacks are an assortment of symptoms that last from a few hours to days. The key to successful treatment is to understand that migraine attacks can be limited in duration and frequency. This can enable you to regain control and get on with your life without fearing the next attack.

Q:	How can I ask my family, friends, and colleagues to deal with my migraine?
A:	You start by involving them in your treatment. The adjustments required to treat migraine aggressively not only affect the individual with the condition but family, loved ones, and coworkers. Migraine sufferers are often reluctant to make changes, fearing the reaction of others to their condition. However, once those around you understand the condition, they are likely to be supportive.

Q:	When should I become concerned about my attacks?
A:	Since migraine can be a progressive illness you must prevent attacks if they become frequent. If you start experiencing more than 3 headache days a month, you must start a preventive migraine treatment program.

How can I prevent migraine attacks?

You can prevent migraine attacks by limiting or reducing the excitability of brain cells. Think of your brain as turning on a migraine attack. You always have the potential for having a migraine. A migraine treatment program is like a software program that filters an unwanted migraine attack. There are many ways to prevent attacks, all of which decrease the excitability of brain cells, thus reducing the brain’s ability to start a migraine attack.

How do medications work to prevent migraine?

Medications used to prevent migraine attacks work in different ways. Some decrease the effect of epinephrine on brain cells, while others increase serotonin or function like serotonin. Treatment may be as simple as one medication, or involve a combination of medications. Eliminating as many triggers as possible reduces the potential for a migraine, and less medication is needed to reduce the likelihood of an attack. With time, many migraine sufferers are able to eliminate the need for medication once migraine frequency has decreased to fewer than 2 attacks per month.

Q:	So can I simply take a pill for my migraine?
A:	Medication may stop your migraine. However, as effective as current medication treatment is today, it cannot prevent or treat every attack. The more frequently you experience attacks, the more likely it is that your migraine will get worse and that you will develop central sensitization. Avoidance of migraine triggers is an important part of your treatment program.

Why would I want to take a pill every day when I only have a migraine once in a while?

The objective in using migraine preventive medications is to help prevent migraine attacks and reduce the severity of an attack. Migraine is a progressive illness. If attacks occur more than once a week, the illness is likely to progress to chronic daily headache (more than 15 headache days a month). Preventive medications help augment the comprehensive migraine treatment program. You and your doctor can decide the best medication for your treatment based on the migraine or headache type, the severity and frequency of your attacks, additional illnesses that may be worsened or helped by the medication, and the presence of medication overuse headache.

What if I have tried preventive medication and it did not work?

It is not uncommon for people with longstanding migraine to lose faith in preventative medications. They feel they have seen enough of doctors and pills. Many times the preventive medications were tried for too short a time, the dose was too high and caused side effects, or the migraine sufferer was still using medication aimed at stopping an attack that made the preventive medication ineffective. It is essential that migraine is not undertreated. You must not give up on preventive treatment because by doing so you risk developing chronic daily headache.

When do I need to take preventive migraine medication?

Starting a daily preventive medication depends on how well you are responding to your comprehensive treatment program. Lifestyle changes may reduce the frequency and severity of attacks without preventive medications. If migraine attacks last more than 2 hours and occur more than once a week, preventive medications are needed. Preventive medications can be stopped if you do not have a migraine for more than 8 months.

Q:	Can pills for high blood pressure (antihypertensives) prevent migraine?
A:	Yes, beta-blockers and calcium channel blockers are types of antihypertensive medicines that can help prevent migraine. However, it is not understood exactly why these medications prevent migraine attacks.

What are beta-blockers?

Beta-blockers are medications used to block epinephrine. Although this group of medications has not been compared in formal studies to the other medications for preventing migraine, they are still some of the most effective medications for migraine prevention. The medications were initially used to treat hypertension (high blood pressure), but are now used in treating heart disease, heart rhythm problems, and anxiety. Only two of the medications have been studied thoroughly enough in the treatment of migraine so far to obtain approval from the US Food & Drug Administration (FDA).

Q:	How do doctors think beta-blockers may prevent migraine?
A:	Beta-blockers work by blocking receptors for epinephrine, a chemical responsible for the “fight-or-flight” response. They may help prevent migraine by controlling the hyperactivity of the epinephrine system that occurs in people with migraine, but no studies have proven this.

What are the possible side effects of beta-blockers?

The possible side effects vary with each individual and the dose of the medication. The side effects may decrease or disappear with time and are less troublesome if the initial dose is low and then slowly increased, if needed. The possible side effects include fatigue, drowsiness, orthostatic hypotension (drop in blood pressure on standing), depressed mood, sexual dysfunction, exercise intolerance (tiring quickly during exercise), aggravation of asthma, weight gain, sleep disturbances, and vivid dreams.

How do calcium channel blockers prevent migraine?

The electrical activity of brain cells occurs because substances called electrolytes cross the brain cell membranes much like a current in a battery. The tiny channels through which the electrolytes, such as sodium and chloride, flow are “gated” by calcium. The calcium channel blockers interact with this process and decrease the electrical activity. This interaction may be why these particular drugs help prevent migraine. The only calcium channel blocker available in the US that has been found to be somewhat helpful with migraine is verapamil. It is especially useful for basilar migraine, hemiplegic migraine, and migraine with aura .

Q:	What are the possible side effects of calcium channel blockers?
A:	As with other medications, side effects vary with each individual and the dose. The possible side effects include fluid retention, sexual dysfunction, including decreased sperm motility (the ability of sperm to move or swim), constipation, weight gain, and heart block (interference with the heart’s electrical conducting system).

How are antidepressants used for migraine prevention?

There are no large well-controlled studies that prove antidepressants help prevent migraine, so they have not been approved by the FDA for treatment of migraine. But many headache specialists find this group of drugs do help. It is assumed these drugs work by affecting serotonin (a brain communication chemical), much as they work for depression, anxiety, and other serotonin-related disorders. The types of antidepressant that are used for migraine prevention are tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and serotonin and norepinephrine reuptake inhibitors (SNRIs).

Q:	What are the possible side effects of antidepressants?
A:	The side effects of antidepressants vary, depending upon the dose and individuals. The possible side effects are sedation, weight gain, dry mouth, urinary retention, constipation, orthostatic hypotension (a sudden fall in blood pressure on standing), and sexual dysfunction.

How can medication used for epilepsy or seizures prevent migraine attacks?

Anticonvulsants (neurostabilizers) are medications used to prevent seizures. This group of medications has shown promise in treating migraine. It is not surprising that these medications work for migraine since, like epilepsy or a seizure disorder, migraine is cause by hyperexcitable brain cells. These medications work by stabilizing the electrical activity of brain cells, thus preventing a wave of excitation from spreading across the brain.

Q:	What are the possible side effects of anticonvulsants (neurostabilizers)?
A:	The possible side effects of anticonvulsants can vary. These include fatigue or irritability, weight gain or weight loss, pins and needles sensation in the arms and legs, and swollen hands and feet. Most side effects are temporary; if they are intolerable, another medication can be used.

How will I know which medication is right for me?

It is important to discuss treatment options with your doctor. You can overlap your treatment of migraine with that of another medical problem. If you have high blood pressure, then beta-blockers may help treat both. In individuals with migraine and depression and/or anxiety, one of the antidepressants may help. However, if you have a problem that might be complicated by the medication, such as asthma with beta-blockers or weight gain with antidepressants, then an anticonvulsant such as topiramate may be the best choice.

Q:	What if I am sensitive to certain medications?
A:	Sensitivity to some medications is not uncommon for people who have sought treatment for migraine. For many, the medication was started at a dose higher than they could tolerate, while others were not aware that certain side effects can go away with time or with a lower dose.

Q:	How can I avoid side effects as much as possible?
A:	Some side effects are unavoidable. If a particular side effect is intolerable, you need to try a different medication. Most medications can be used successfully if the initial dose is small and gradual increases in dose are made slowly over time. Using a liquid, a sprinkle formulation, or a pill cutter can be very helpful in the beginning.

What if I tried a medication that was somewhat helpful but then the larger dose caused side effects?

Adding a second medication from a different group of preventive migraine medications may be helpful. This approach allows you to use two medications at a lower dose rather than one at a high dose, with consequent side effects. Maintaining an aggressive comprehensive treatment program that includes avoiding migraine triggers, regular exercise, and stress management should eliminate the need for excessive medication.

What if I forget to take a medication?

When you forget to take a medication, you may trigger a migraine attack or suffer from side effects, especially with antidepressants. It is important to take the medication as directed by your doctor. Initially, the medication will be more effective if you take regular pills twice a day. With better migraine control, you can change to the long-acting form called sustained release. Sustained release pills are usually taken only once a day and it is easier to remember to take them.

How can I remember to take my medication?

You can use a pill container with sections for each day of the week. But keep the medication out of the reach of children since most of these containers are not child-resistant. Taking your medication before a daily activity such as brushing your teeth, shaving, or showering may also be helpful. Some medications need to be taken at bedtime or after a meal, so check with your doctor for instructions regarding drug administration.

Will I have to take medication daily for the rest of my life?

Migraine differs from person to person. For most people with migraine, daily medication can be tapered off and eventually discontinued if migraine attacks drop to less than twice a month. The thought of stopping your daily medication should motivate you to treat your migraine with a comprehensive program. Once you have reduced the frequency of attacks, you should be able to maintain migraine control without daily medication if you continue to avoid triggers, reduce stress, and exercise regularly.

Q:	How long does it take for a preventive medication to start to “work?”
A:	Preventive medications need at least a month to work once you have achieved an effective dose. Each medication will continue to become more effective over the succeeding 3 months. You cannot determine whether or not a medicine has been ineffective until you have taken it for 4 months.

Q:	How does one determine if the medication is “working?”
A:	An effective preventive migraine medication needs to reduce the frequency, severity, and duration of your migraine attacks. A medication is deemed effective if it reduces frequency of migraine attacks by more than 50 percent. If the frequency of your migraine attacks has not been reduced by at least this amount, you need to change the treatment approach.

Taking medication

Understanding how migraine medications work as part of your comprehensive treatment program to prevent migraine attacks is essential for your success. The following tips will help you get the most out of your preventive medications.

Be realistic about what you think a medication can do for you.
Understand how the medication helps prevent migraine attacks.
Be aware of the potential side effects, both temporary and long-term.
Understand which side effects mean you should to stop taking the drug.
Know that all drugs have side effects; most disappear as medication is continued. Low doses taken initially and slowly raised have fewer side effects.
Combine an aggressive nondrug treatment program to reduce migraine triggers with preventive medication for the best outcome.
Be aware that preventive migraine medications take 3–4 weeks to start working and should be used for 12 weeks at the correct dosage to see if the drug is effective.
Remember that preventive medication will not work if you take any that cause medication overuse headache.

Medications Used for Migraine Prevention

No medications have been developed solely for the purpose of migraine prevention. However, medications used to treat other medical conditions have been found to prevent migraine. The main classes of medication used to prevent migraine are antihypertensives (used for high blood pressure), antidepressants (used for anxiety and depression), and anticonvulsants/neurostabilizers (used for epilepsy or seizures). Antihypertensives used for migraine may be either beta-blockers or calcium channel blockers. Antidepressants used for migraine may be tricyclic, selective serotonin reuptake inhibitors (SSRIs), or serotonin and norepinephrine reuptake inhibitors (SNRIs). Some of these medications have undergone scientific study and are now approved by the Food & Drug Administration (FDA) to treat migraine. In the US, a medication does not have to be approved for a particular medical condition for it to be used to treat that disease; it only has to be approved for use in the US by the FDA.

Migraine preventive medications

Table
Antihypertensives	Usual effective dose (mg)	FDA approved
Beta-blockers
Propranolol	60–320	Yes
Timolol	20–60	Yes
Atenolol	50–200	No
Metoprolol	50–200	No
Nadolol	20–240	No
Calcium channel blocker
Verapamil	80–360	No

Table
Anticonvulsants (neurostabilizers)	Usual effective dose (mg)	FDA approved
Divalproex sodium	500–1,000	Yes
Topiramate	50–200	Yes
^[]Levetiracetam	750–3,000	No
Gabapentin	1,200–3,000	No
Lamotrigine	100–200	No
^[]Zonisamide	100–300	No

Table
Antidepressants	Usual effective dose (mg)	FDA approved
Tricyclic antidepressants
Amitriptyline	25–150	No
Nortriptyline	25–150	No
Protriptyline	10–40	No
Doxepin	25–200	No
^[]Imipramine	25–150	No
Desipramine	25–150	No
Selective serotonin reuptake inhibitors (SSRIs)
^[]Paroxetine	20–40	No
^[]Fluoxetine	20–40	No
^[]Escitalopram	10–40	No
^[]Sertraline	25–100	No
Serotonin and norepinephrine reuptake inhibitors (SNRIs)
Venlafaxine	37.5–150	Yes
^[]Duloxetine	20–60	No

*Although these medications have been found helpful for migraine prevention, some specialists do not recommend routine use because scientific evidence is insufficient.