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Preventing a Migraine Headache (Preventative Medications)

iHeadache Electronic Headache Diary

Migraine prophylaxis or migraine prevention refers to the use chronic treatment of patients in order to prevent the development of a migraine headache from occurring.  Most patients with recurrent headaches that are frequent and disabling have migraine headaches. Therefore recurrent headache treatment usually includes taking a daily medication but this is not always the case. Most neurologists would agree that patients who have two (2) or more headaches (of any type) a week should be placed on a preventative to decrease the risk of their headaches becoming rebound. Even patients with fewer headaches that do not respond to acute treatment should be considered.

It is critical that the patient has a physician who listens to them and takes a history as to the number of headache free days and not just the "migraine days" or severe headache days. Dr. Loftus thinks of migraine treatment as a "team sport" and it is most critical in patients with frequent migraine requiring a prevention. See what Dr. Loftus' patients say about his practice here.

Rebound headache is a type of daily headache which occurs from the overuse of pain medications and is much more difficult to treat than frequent sporadic migraines.  The use of prophylaxis in patients having fewer than two headaches a week is common and depends upon headache frequency, the severity of the headache, the length of the individual headache, and the response to acute headache therapy. In some patients having even one or two disabling headaches each month is enough to justify migraine prevention. Basically the patient and physician have to decide it is beneficial for the patient to take a preventative rather than to just treat the migraine when it occurs.

There is no official diagnosis of cluster migraine headache. You either have I.H.S. cluster headache or I.H.S. migraine headache.{Cephalgia 2004;24 (Suppl 1)} On a rare occasion, it may be difficult to determine if a patient's headaches are migraines or cluster. In my experience, most patients using the terms "cluster migraine," "cluster migraines," or "cluster migraine headaches" have frequent migraine headaches that cluster together in time. The term, "cluster migraine", should be avoided to prevent confusion with the diagnosis of cluster headache.

Before choosing any preventative, it is important to eliminate frequent headache triggers. For many patients, the most common triggers include irregular sleep, missed meals, caffeine, and chocolate. Dr. Loftus does not believe in looking at individual foods as triggers until the headaches are relatively sporadic. Some other common triggers are menstrual cycles, weather fronts, and stress releases but these cannot be prevented.

Once the above preventative measures are being followed, the next most important step is to make sure the patient is not potentially having rebound headaches. Any medication that is being taken twice or more weekly could potentially be causing rebound headaches however; rebound headache causing medications are typically taken on a near daily basis. No migraine prevention program will be successful if the patient continues to take a rebounding medication.

How Can I Help My Doctor Help Me

You need to gather real time information on your headaches. Your physician needs the number of headaches, medication usage, and disability. It is also helpful to have your headaches properly classified. Dr. Loftus designed the iPhone and iPod touch app iHeadache to do all of this for you. The value of iHeadache is that it will produce reports that you and your physician will be able to use to properly diagnose your headache, determine if prevention is warranted, and to determine over time if therapy is working.

The next step is to choose a migraine prevention medication. Fortunately there are many choices. In general, the selections process initially begins with one of the highly effective migraine preventatives and then moves to less proven or less robust agents when the better agents are either not successful, not tolerated, or have side effects that makes patients want to avoid them completely. Dr. Loftus calls this method “intelligent trial and error.” Dr. Loftus considers 7 agents potential oral agents for first line therapy for frequent migraine prevention and chronic migraine prevention. The are amitriptylene, duloxeitne, propranolol, candesartan, topiramate, zonisamide, and valproic acid.

Elavil® (amitriptylene)

The primary advantage of Amitriptylene or Elavil® is that it is the cheapest preventative available. The monthly cost can literally be $5 per month. Unfortunately, the medication has a high percentage of side effects. Dry mouth, sedation, constipation, and weight gain are typically limiting side effects.

Inderal® (propranolol)

The next oldest, well established preventative is propranolol or Inderal®. This medication can worsen asthma, makes patients fatigue, and limit aerobic exercise but in general is fairly well tolerated. It is relatively inexpensive as well with a twice-daily generic form running about $20 per month. It is generally thought of as a weight neutral medication but all patients should be monitored for weight.

Topamax® (topiramate) and Zonegran® (zonisamide)

A third preventative is topiramate or Topamax®. This medication, first licensed as an antiepileptic medication, is the most popular medication currently prescribed by neurologists for headache prevention. While not more effective than the other first line agents, it is the only one that is clearly associated with weight loss. The average obese patient can expect to lose about 10% of their body weight over one year. Since obesity is a risk factor for frequent migraines over time, a large number of migraine patients who need preventatives are medically overweight or obese. Unfortunately topiramate does have a lot of side effects. Some side effects are more of a nuisance. Carbonated drinks taste badly while taking this drug and some patients experience tingling around the mouth, finger, or toes. Renal or kidney stones occur about 1% of the time and is the only side effect which does not go away when topiramate is discontinued without additional therapy. A small percentage of patients have an altered ability to think on the medication that commonly expressed as a word finding problem. This returns to normal with reduction or discontinuation of the medication. Finally there is a very rare condition of acute narrow angle glaucoma that is very painful but again resolves with discontinuation of the medication and specific medical therapy. The cost is typically $20-$30 per month.

Zonegran® or zonisamide is another antiepileptic medication with weight loss similar to topiramate. It has fewer mental side effects. In the only head to head study done between the two, they were equally effective for migraine prevention. Zonegran or zonisamide is generally avoided in sulfa allergic patients and tends to have a higher incidence of nausea than topiramate. The cost is typically $20-$40 per month.

Depakote ER® or valproic acid

The last of the big four preventatives is valproic acid and is typically $20-30 per month. The most convenient form for patients is Depakote ER® which is a once daily migraine prevention agent. Depakote ER® can cause birth defects and therefore, Dr. Loftus generally will not prescribe it to women who could become pregnant. In addition, valproic acid can cause weight gain and liver enzyme problems. Despite these warnings, the medication is generally well tolerated and can be used quite safely. However, given the issue with birth defects it is most commonly prescribed to males with migraines who are not overweight. Valproic acid is also widely used as an anticonvulsant.

Botox® (onabotulinum) brand botulinum toxin

Botox® is FDA approved for the prevention of headaches in patients with chronic migraine. Because it is one of the more expensive therapies for migraine prevention, it is generally used after patients fail other therapies.  Also, because of its cost Dr. Loftus feels it is essential for patients to keep a headache diary with disability information.  This allows one to determine that the treatment is clearly helpful as well as provide an early warning when the medication is wearing off. The cost is about $500 per month.

Cymbalta® (duloxetine)

Another SSNRI on the market is duloxetine or Cymbalta®. It is relatively more balanced than Effexor® and therefore is easier to titrate. It does cause the same amount of nausea as Effexor but is associated with less sexual dysfunction and less hypertension. To date, there are no double blind studies proving its effectiveness in migraine prevention. Cymbalta is FDA approved in depression, anxiety, fibromyalgia, pain from osteoarthritis, and diabetic neuropathic pain. Since 33% to 66% of patients with chronic migraine also have depression, the use of Cymbalta® as a first line agent makes sense for those patients with depression as the medication is FDA approved for their depression. Until it becomes generic in December 2013, it will be relatively expensive at $200 per month (but still much less than Botox®.

Botox® (onabotulinum) brand botulinum toxin

Botox® is the only FDA approved for the prevention of headaches in patients with chronic migraine. Because it is one of the more expensive therapies for migraine prevention, it is generally used after patients fail other therapies.  Also, because of its cost Dr. Loftus feels it is essential for patients to keep a headache diary with disability information.  This allows one to determine that the treatment is clearly helpful as well as provide an early warning when the medication is wearing off. The cost is about $500 per month.

Sphenopalatine Ganglion (SPG) block

SPG block is now possible using a device that is placed by a physician througth the nose. One of these devices is Allevio™. With this device, lidocaine, a local anethetic is used to produce the block. It also blocks the 2nd branch of the trigeminal nerve. This treatment not only treats an acute headache but appears to help prevent future headaches. There is limited controlled data at this time. Most insurances will pay for this therapy at this time. This therapy is safe to be used during pregnancy. Bellaire Neurology currently offers this therapy to patients.

Pericranial Nerve Blocks

There are many different nerve block procedures used by different physicians to treat frequent and chronic migraine. The fact that they can work at times does not prove that the migraine is being triggered by various injuries to the nerve. Dr. Loftus prefers a technique made popular by Dr. Kaniecki that blocks occipital nerves as well as various branches of the trigeminal nerve rather than occipital nerve blocks alone.

Migraine Surgery

Many physicians - with very limited open label trials, are offering various procedures to cut or decompress various nerves for the treatment of migraine headaches. Most of these physicians are not particularly trained in the diagnosis of migraine and even advertise themselves as "curing" migraine headaches. The data is lacking and there is the possibility of patients getting worse with some of these treatments. It is the position of the American Headache Society that Migraine Surgery should not be performed outside of a controlled study. Until you have tried the 7 first line medications on this page, Botox, sphenocath, and pericranial nerve blocks I would strongly urge you to not consider Migraine surgery. If your physician promises a cure, then run away. Easy questions that help you establish the "Migraine or Headache" credentials of a physician can be a simple as - which of the following societies do you belong to - American Headache Society, Southern Headache Society, etc. How many meetings of these societies have you attended in the past 3 years?

Neurostimulators and Migraine

There is some limited data to support neurostimulations in chronic migraine. The most popular procedure is the Reed procedure. A well controlled European trial indicates that 50% of pateints will require multiple surgical procedures to fix various problems with the stimulators. This is a reasonable treatment for those that have failed all of the 7 first line medications, Botox, sphenocath, and pericranial nerve blocks. Again, if your physician promises a cure, then run away. Unfortunately, even those that benefit from a stimulator trial commonly do not do well with the surgery.

Verapamil, Coenzyme Q10, Botox® and PFO

There are studies demonstrating verapamil to be a good anti-migraine agent although not as robust as the medications previously mentioned. Coenzyme Q10, which is available over the counter, was demonstrated in one small placebo controlled trial to be beneficial. The data on botulinum toxin type A or Botox® is quite extensive. Despite this, there continues to be a lot of controversy over its use. It does appear to help some patients with frequent migraines but this is off label according to the FDA.

There has been a lot of interest in the closing of a patent foramen ovale or PFO (a small channel between the right atria and left atria) of the heart for the prevention of migraines. Certainly patients with migraines have an increased risk of PFOs and their PFOs tend to be larger. There is some open label data that to suggest closing this hole or channel lessens the incidence of migraine. Well controlled studies have failed to provide benefit but more studies are ongoing.

The most important thing to remember is that there are numerous agents that one can try for migraine prevention. It is most likely that at least one of them will work well for you. Unfortunately prevention therapies are under utilized, resulting in excessive disability for migraine patients. If you are having frequent headaches, please see your neurologist and ask to be placed on prevention. If you have frequent headaches and are not being offered prevention, then you really need to change physicians.