For those of us with three or more Migraine attacks a month and those of us whose Migraine attacks are especially severe and debilitating, it’s generally recommended that we work with our doctors to find effective Migraine prevention.
At this time, there are no medications on the market that were originally developed for Migraine prevention. The medications in use were developed for other diseases and conditions, and people with Migraine using them for those conditions found that they also helped with Migraine prevention. A few of these went on to get FDA approval for Migraine prevention, but the vast majority of them a prescribed off-label. Off-label prescribing is a very common practice, not only for Migraine, but for other diseases as well.
The medications that have received FDA approval for Migraine prevention are:
- propranolol (brand name Inderal),
- timolol (brand name Blocadren),
- divalproex (brand name Depakote),
- topiramate (brand name Topamax, Trokendi, Qudexy),
- erenumab (brand name Aimovig™)
- fremanezumab (brand name Ajovy™),
- galcanezumab (brand name Emgality™), and
- onabotulinumtoxinA (brand name Botox), which is approved only for Chronic Migraine.
We finally have access to two medications that was developed specifically for Migraine prevention. Aimovig™ is the first biologic developed for Migraine and is FDA approved for Migraine prevention. Aimovig™ is a CGRP monoclonal antibody (a biologic) that is self-administered via subcutaneous injection every 30 days. Ajovy™ is also a CGRP monoclonal antibody, and is self-administered via subcutaneous injection every 30 or every 90 days.
In recent years, devices for Migraine prevention have been researched. One of them, the Cefaly, has received FDA approval for Migraine prevention. The second, the Spring TMS (transcranial magnetic stimulation) device, has received FDA approval for the acute treatment of Migraine with aura and is currently in clinical trials in the United States for Migraine prevention. It has received approval as a Migraine prevention in Europe.
There has also been quite a bit of research and clinical trials of neurostimulators for Migraine prevention. HOWEVER, none of them are FDA approved at this time. Despite several clinical trials of implantable occipital nerve stimulators for Migraine, they are not FDA approved. This doesn’t mean that patients shouldn’t investigate and consider them, but anyone considering them should know that they actually failed to meet their endpoints in clinical trials.
Unfortunately, it’s difficult — if not impossible — to predict which prevention therapies will work best for any individual patient. That leaves us with having to try them to see if they work or not, and to give a preventive treatment a fair try, we need to try it for about three months. This takes time and patience, but it well worth it when we find what works for us. Something we need to know and keep in mind when trying preventive medications is that trying one medication from a family of medications doesn’t tell us anything about how our bodies would respond to another medication in that family. For example — if one calcium channel blocker does nothing for us, that doesn’t meant that a different one has no chance of working for us.
The hopeful and positive side of this is that we now have so many options that it’s nearly impossible to have tried everything. To give each of the medications now in use as Migraine prevention a fair three-month trial would take in excess of 25 years, and that doesn’t even count the devices.
To help you prepare for your next doctor’s appointment, satisfy your curiosity, and give you hope, I’ve put together a list of medications and devices currently in use for Migraine prevention. I’m listing the medications by their drug category.
ANTIHYPERTENSIVES (blood pressure meds)
- clonidine, brand Catapres
- guanfacine, brand Tenex, Intuniv
- benazepril, brand Lotensin
- captopril, brand Capoten
- enalapril, brand Vasotec
- fosinopril, brand Monopril
- lisinopril, brand Zestril, Prinivil
- moexipril, brand Univasc
- perindopril, brand Aceon
- quinapril, brand Accupril
- ramipril, brand Altace
- trandolapril, brand Mavik
Angiotensin II Inhibitors:
- candesartan, brand Atacand
- eprosartan, brand Teveten
- irbesartan, brand Avapro
- losartan, brand Cozaar
- olmesartan, brand Benicar
- telmisartan, brand Micardis
- valsartan, brand Diovan
- acebutolol, brand Secral
- atenolol, brand Tenormin
- betaxolol, brand Kerlone
- bisoprolol, brand Zebeta, Emconcor
- cartelol, brand Cartrol
- carvedilol, brand Coreg
- esmolol, brand Brevibloc
- labetalol, brand Normodyne, Trandate
- metoprolol, brand Toprol
- nadolol, brand Corgard
- penbutololm brand Levatol
- pindolol, brand Visken, Syn-Pindolol
- propranolol, brand Inderal
- sotalol, brand Betapace
- timolol, brand Blocadren
Calcium Channel Blockers:
- amlodipine, brand Norvasc
- bepridil, brand Vascor
- diltiazem, brand Cardizem, Tiazac, Cartia
- felodipine, brand Plendil
- flunarizine, brand Sibelium (Canada)
- isradipine, brand DynaCirc
- nicardipine, brand Cardene
- nifedipine, brand Adalat, Procardia
- nimodipine, brand Nimotop
- nisoldipine, brand Sular
- verapamil, brand Calan, Verelan, Isoptin
- trandolapril/verapamil, brand Tarka (ACE inhibitor/calcium channel blocker)
- enalapril/felodipine, brand Lexxel (ACE inhibitor/calcium channel blocker)
- amlodipine/benazepril, brand Lotrel (calcium channel blocker/ACE inhibitor
- cyproheptadine, brand Periactin
- pizotifen, brand Sandomigran (UK)
Tricyclic antidepressants (TCAs):
- amitriptyline, brand Elavil (discontinued), Endep
- amoxapine, brand Asendin
- clomipramine, brand, Anafranil
- desipramine, brand Norpramin
- doxepin, brand Sinequan
- imipramine, brand Norfranil, Tofranil
- nortriptyline, brand Pamelor, Aventyl
- protriptyline, brand Vivactil
- trimipramine, brand Surmontil
- isocarboxazid, brand Marplan
- phenelzine, brand Nardil
- tranylcypromine, brand Parnate
Selective serotonin reuptake inhibitors (SSRIs):
- citalopram, brand Celexa
- escitalopram oxalate, brand Lexapro
- fluoxetine, brand Prozac
- fluvoxamine, brand Luvox
- paroxetine, brand Paxil, Paxil CR, Pexeva
- sertraline, brand Zoloft
Selective serotonin and norepinephrine reuptake inhibitors (SNRIs):
- desvenlafaxine, brand Pristiq
- duloxetine hydrochloride, brand Cymbalta
- milnaciptan, brand Savella
- venlafaxine, brand Effexor, Effexor XR
- bupropion, brand Wellbutrin, Zyban
- mirtazepine, brand Remeron
- trazodone, brand Desyrel
- acetazolamide, brand Diamox
- methazolamide, brand Neptazane
ATTENTION DEFICIT HYPERACTIVITY DISORDER MEDS:
Selective Norepinephrine Reuptake Inhibitor:
- amphetamine/dextroamphetamine, brand Adderall
- atomoxetine HCl, brand Strattera
- methylphenidate, brand Concerta
Cox-2 Enzyme Inhibitors:
- celecoxib, brand Celebrex
NEURONAL STABILIZING AGENTS (antiseizure medications):
- carbamazepine, brand Tegretol
- clonazepam, Klonopin
- clorazepate, brand Tranxene
- divalproex, brand Depakote
- gabapentin, brand Neurontin
- levetiracetam, Keppra
- lamotrigine, brand Lamictal
- pregabalin, brand Lyrica
- oxcarbazepine, Trileptal
- tiagabine, brand Gabitril
- topiramate, brand Topamax
- valproate Sodium, brand Depacon
- lacosamide, brand Vimpat
- zonisamide, brand Zonegran
- montelukast, brand Singulair
- zafirlukast, brand Accolate
- zyleuton, brand Zyflo
ATYPICAL ANTIPSYCHOTIC MEDICATIONS:
- olanzapine, brand Zyprexa
- quetiapine, brand Seroquel
- ziprasidone, brand Geodon
- coenzyme Q10
- feverfew (Should not be used by women who are or could become pregnant.)
- butterbur, brand Petadolex
- vitamin B2
- 5-HTP (Check carefully with doctor because of interactions with meds including triptans)
DEVICES AND APPLIANCES:
- gammaCore Sapphire Vagus nerve stimulator: The Sapphire nVNS device is a hand-held device about the size of a cell phone that can be carried in a purse or backpack.
- eNeura’s sTMS Mini Device: The sTMS Mini is a single-pulse Transcranial Magnetic Stimulation (sTMS) device approved by the FDA for the acute treatment of migraine with aura in 2014. For more information, see Acute Migraine Treatment – Spring TMS Device Finally Approved FDA.
- Cefaly: The Cefaly is an external trigeminal nerve stimulator (eTNS) device that was approved by the FDA for migraine prevention in 2014. For more information, see Cefaly Device Approved by the FDA for Migraine Treatment.
- NTI Tension Suppression System (NTI-TSS): If a temperomandibular joint disorder (TMJ), bruxism (grinding your teeth), or clenching your jaw are Migraine triggers for you, you may want to check into the NTI Tension Suppression System (NTI-TSS). This is a small dental appliance worn at night to keep the molars and canines from touching. It was developed by Dr. Jim Boyd, and has been helpful for people with these triggers. (See www.nti-tss.com.)
- Loder, Elizabeth, MD, MPH; Burch, Rebecca, MD; Rizzoli, Paul, MD. “The 2012 AHS/AAN Guidelines for the Prevention of Episodic Migraine: Summary and Comparison with other Recent Clinical Practice Guidelines.” Headache. Accepted manuscript online: April 26, 2012.
- Silberstein, S.D.; Holland, S.; Freitag, F.; et. al. “Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults : Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society.” Neurology 2012;78;1337.
- Holland, S.; Silberstein, S.D.; Freitag, F.; et al. “Evidence-based guideline update: NSAIDS and other complementary treatments for episodic migraine prevention in adults : Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society.” Neurology 2012;78;1346.
- Kotz, Deborah. “How to get better treatment for migraines.” The Boston Globe. April 30, 2012.
- Gardner, Amanda. “Migraine Guidelines: What Works, What Doesn’t.” Philly.com. April 24, 2012.
- Email interview with Dr. Elizabeth Loder. April 23, 2012.
- Ramadan, Nahib M., MD; Silberstein, Stephen D., Md, FACP; Frietag, Frederick G., DO; Gilbert, Thomas T., MD, MPH; Frishberg, Benjamin M., MD. “Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management for Prevention of Migraine.” American Academy of Neurology Practice Guidelines. September, 2000.