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If you experience more than 4-5 migraine days in a month, or approximately one day of migraine a week, your doctor may recommend a medication to help prevent your headaches. The types of medications used to prevent migraine vary significantly, and your doctor may give you a number of options initially. Most doctors will help you choose the right preventive medications based on your own unique circumstances, and balance benefit with potential side effects.
You might start with a vitamin preventive. These are great if you have a lower frequency of migraine attacks, or if you aren’t yet ready to start a formal medication. The vitamin supplements that help migraine can also be added to any of the medications if necessary.
There are five classes of medications that can help prevent migraine: antihypertensives (blood pressure medicines), antidepressants, anti-seizure medications, CGRP antibodies, and Botox. We will discuss these each below.
This family of medications was the first initially used to prevent migraine. Many of these medications have been around for a long time, and have a great safety profile. The theory as to how these medicines help, is based on their ability to regulate blood vessels around the brain, decreasing the changes in blood vessel dilation that occurs during migraine.
The medications in this class are propranolol, atenolol, nadolol, lisinopril, verapamil and candesartan. These are great choices for people that otherwise have high blood pressure, but would not be appropriate if your blood pressure typically runs low. The most common side effect with this class is light-headedness.
Antidepressants can help prevent migraine, even if you aren’t feeling anxious, depressed, or have any other issues with your mood. In fact, most of the best antidepressants for mood don’t help migraine much at all. Antidepressants help to regulate the brain’s neurotransmitters, many of which become dysregulated before and during a migraine attack.
The medications in this class are amitriptyline, nortriptyline, venlafaxine and duloxetine. These medications can also be helpful for other musculoskeletal pain, so they might be a great choice if you also have neck or back pain, or tension type headache. Some can help sleep, some have a stimulant effect and can give you a boost of energy.
Anti-seizure medications help regulate the electrical activity of the brain, which can also become affected by migraine. This is the case even if you don’t experience aura with your migraine. The medications in this class are mostly quite potent, but may be a bit more difficult to tolerate.
These medications are topiramate, depakote, gabapentin and zonisamide. The most common side effects are weight loss, numbness/tingling in the fingers and toes, sleepiness and “brain fog” - feeling cognitive slow, having difficulty finding words. Some people notice an edge to their mood, or even a worsening to their anxiety.
This might be a good choice if you need something more potent, or to also help weight loss, but would not be a great choice if you already have depression or anxiety.
This class was the first developed to prevent migraine specifically. These medications are once monthly injectables, containing antibodies that specifically block a protein in the brain called CGRP (calcitonin gene related peptide) that causes migraine.
These medications are Aimovig, Ajovy, and Emgality (a new IV version is now available as well called Vyepti which is given every three months). Because these antibodies may affect fetal development, we don’t recommend them if you are planning pregnancy within 5 months, or if you are breastfeeding.
The most common side effects for this class are skin irritation at the injection site, and soreness. Aimovig can be associated with constipation as well. Because these medications are new, most insurance require that you try some of the oral medications first before trying the CGRP antibodies.
Atogepant (brand name Qulipta) is also another new option.
Botox is a neurotoxin that was initially only used cosmetically, but found to be effective in preventing chronic migraine. The best protocols for how to give Botox were studied for many years, and in 2010 the FDA approved Botox for people who have this migraine subtype. Chronic migraine is defined as experience more than 15 days of headache per month, the majority of which with feature of migraine - like the throbbing pain, light or sound sensitivity, or nausea.
Botox is injected in a specific protocol, and is given even 3 months. The effects of botox only begin about 7-10 days after the injection - it is slow in onset, but lasts a long time. Each injection is typically more effective than the previous one, so we say that the effects are cumulative.
The most common side effect is pain at the injection sites, soreness and actually - headache! The headache after Botox is usually very transient, and most people continue to do it even though it hurts, because it is very effective, even for some of the most difficult to treat migraine cases. In order for your insurance to authorize Botox, you will also likely need to try at least one medicine in at least one of the oral classes of medications.
If you are looking for a preventative solution to treat your migraine but still need more information, join Neura Health and talk to our team about it.