migraine preventives: which one will work for you?
there's no 'best' preventive for migraine, but there are options.
3 minute read
sadly, we don’t know what the best preventive for migraine is. many different approaches exist, and it is not possible to predict which one will work for one person in particular. for every option, there are people who do not improve (non-responders), people who improve partially (30 per cent to 50 per cent who are partial responders), and people who improve a lot (75 per cent, known as super-responders).
the same applies to side effects, which cannot be predicted: some people have them and others don’t.
how do i decide which preventive to try?
medical reasons. your physician must check which preventive you cannot use for medical reasons (contra-indication). example: people with asthma should not use beta-blockers.
side effects. see if the side effect profile is acceptable for you. for example, if you are overweight, a medication causing weight gain is not ideal. likewise, if you have insomnia, a medication causing somnolence taken at bedtime could be good.
insurance coverage. some drugs can be used only as second or third-line, after trying cheaper drugs. for example, in canada, botox and cgrp antibodies will not be covered if you have not tried two other preventives.
table of migraine preventives
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this table is an overview of options. a more detailed table is also available with doses, contra-indications and common side effects.
class: anti-hypersensitive
examples generic (brand name): candesartan (atacand), propranolol (inderal), nadolol (corgard), verapamil (isoptin)
how does it work: unclear. some decrease the electrical hyperexcitability of the brain.
examples generic (brand name): candesartan (atacand), propranolol (inderal), nadolol (corgard), verapamil (isoptin)
how does it work: unclear. some decrease the electrical hyperexcitability of the brain.
class: anti-depressant
examples generic (brand name): amitriptyline(elavil), nortriptyline (aventyl), venlafaxine (effexor)
how does it work? modulate pain networks (serotonin, adrenalin, noradrenalin)
examples generic (brand name): amitriptyline(elavil), nortriptyline (aventyl), venlafaxine (effexor)
how does it work? modulate pain networks (serotonin, adrenalin, noradrenalin)
class: anti-seizure
examples generic (brand name): topiramate (topamax), gabapentin (neurontin)
how does it work? decrease the hyperexcitability of the brain neurons
examples generic (brand name): topiramate (topamax), gabapentin (neurontin)
how does it work? decrease the hyperexcitability of the brain neurons
class: cgrp antibodies
examples generic (brand name): erenumab (aimovig), galcanezumab (emgality), fremanezumab (ajovy)
how does it work? block cgrp that plays a role in the migraine cascade designed for migraine
examples generic (brand name): erenumab (aimovig), galcanezumab (emgality), fremanezumab (ajovy)
how does it work? block cgrp that plays a role in the migraine cascade designed for migraine
class: supplements
examples generic (brand name): magnesium, vitamine b2, coenzyme q10, feverfew (petasites or butterbur not used anymore for liver toxicity concerns), vitamin d
how does it work? may influence the energy metabolism of the brain and stabilize neurons
examples generic (brand name): magnesium, vitamine b2, coenzyme q10, feverfew (petasites or butterbur not used anymore for liver toxicity concerns), vitamin d
how does it work? may influence the energy metabolism of the brain and stabilize neurons
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class: injectable toxins
examples generic (brand name): onabotulinum toxin type a (botox)
how does it work? modifies the function of sensory nerves, and decreases the input to the brain
examples generic (brand name): onabotulinum toxin type a (botox)
how does it work? modifies the function of sensory nerves, and decreases the input to the brain
class: neuromodulation
examples generic (brand name): transcutaneous stimulation (cefaly), vagus nerve stimulation (gamma core), transcranial magnetic sitmulation (eneura, not available in canada)
how does it work? influences the pain networks with electrical currents
examples generic (brand name): transcutaneous stimulation (cefaly), vagus nerve stimulation (gamma core), transcranial magnetic sitmulation (eneura, not available in canada)
how does it work? influences the pain networks with electrical currents
table: therapies for which there is no strong evidence that it works more than placebo (more research needed or strong placebo effect suspected).
category: injections
examples: acupuncture, nerve blocks, daith piercing, sphenopalatine ganglion (spg) blocks
hypothetical mechanism (not proven): influence of the energy meridians, muscle and nerve modulation, blocking sensory inputs to the brain, modulation of the vagus nerve function (not proven), modulate the nerve networks passing in this ganglion
examples: acupuncture, nerve blocks, daith piercing, sphenopalatine ganglion (spg) blocks
hypothetical mechanism (not proven): influence of the energy meridians, muscle and nerve modulation, blocking sensory inputs to the brain, modulation of the vagus nerve function (not proven), modulate the nerve networks passing in this ganglion
category: cannabinoids
examples: cannabis, cbd oil (many available with different thc, cbd content and ratios)
hypothetical mechanism (not proven): the cannabinoid system influences virtually every system in the brain, including the pain network but also others
examples: cannabis, cbd oil (many available with different thc, cbd content and ratios)
hypothetical mechanism (not proven): the cannabinoid system influences virtually every system in the brain, including the pain network but also others
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category: surgery
examples: decompression of nerves, neurostimulation with implants
hypothetical mechanism (not proven): relieve the pressure on nervesmodulate the pain system
examples: decompression of nerves, neurostimulation with implants
hypothetical mechanism (not proven): relieve the pressure on nervesmodulate the pain system
category: opioids
examples: morphine and others – should not be used for migraine prevention due to risks
hypothetical mechanism (not proven): act on opioid receptors in the brain (mu, kappa, delta receptors)
examples: morphine and others – should not be used for migraine prevention due to risks
hypothetical mechanism (not proven): act on opioid receptors in the brain (mu, kappa, delta receptors)
a warning: should any drug that treats epilepsy, hypertension or depression be used for migraine just in case it works?
some tables online list many other drugs — especially anti-hypertensives and anti-depressants — that some physicians may use, but have not been studied specifically for migraine. you should be careful. these very long lists are not medically recommended.
for more information on migraine, and to connect with others who share your experience, visit migraine canada.
references
pringsheim t, davenport w, mackie g, worthington i, aube m, christie sn, et al. canadian headache society guideline for migraine prophylaxis. can j neurol sci. 2012;39(2 suppl 2):s1-59.
rajapakse t, pringsheim t. nutraceuticals in migraine: a summary of existing guidelines for use. headache. 2016;56(4):808-16.
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mcgeeney be. cannabinoids and hallucinogens for headache. headache. 2013;53(3):447-58.
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