Preventative Treatment

  • Preventative therapy is considered when headaches become too frequent or when acute medications do not work.

  • Preventative medications do not work right away; it takes time for the body to acclimate to them.

  • When starting preventative medications, the motto is “Start low, go slow.”

  • Only four medications have been approved by the FDA for migraine prevention as of this writing, but many more are also used off-label.

  • Finding the right preventative medication can be complicated; therefore, it is essential to have a partnership with your doctor.

If you do not understand the basic concept of preventative medications, you may become easily frustrated and give up too soon. Most of the preventative medications belong to one of three categories:

  • Antiepileptic (for treating seizures and epilepsy)

  • Antidepressant (for treating depression or other mood disorders)

  • Antihypertensive medications (for lowering one’s blood pressure)

If one medication does not work, you may need to try a different medication. In fact, several trials may be needed before you find the right preventative medication. The medication is started at a low dose and increased slowly to control the dose-related side effects. Prescribing too much medication from the onset will generally cause too many side effects. The start-low go-slow method might frustrate some people because they are unable to experience an immediate effect from the medication. As the therapeutic level of these medications builds up, they become more effective.

Once the decision has been made to use preventative therapies, a physician can choose from four drugs that have been approved by the US Food and Drug Administration (FDA) for prevention of migraine.

These are:

  1. Topiramate (Topamax), an anti-seizure medication

  2. Propranolol (Inderal), a blood-pressure-lowering medication

  3. Divalproex sodium (Depakote), an anti-seizure medication

  4. Timolol (Timolide, Blocadren), a blood-pressure-lowering medication

There is equally strong evidence for the effectiveness and safety among these medications as well as amitriptyline (an antidepressant in frequent use, although not approved by the FDA for migraine prophylaxis).

Most recently, Botox was approved by the FDA for prevention of chronic migraine headaches. It is an injectable drug, and no pill form is available. It is injected approximately every three months around the head and neck region. It does not seem to work as well for headaches occurring less frequently than fourteen days per month. Keep in mind that Botox must be injected by an experienced physician.

The preventative medications need to be taken for an adequate period of time and with the optimal dose before concluding that they are not effective. Research studies show that 40 to 50 percent of people on preventive medications experience more than a 50 percent decrease in their headaches.