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According to the Migraine Research Foundation, migraine headaches affect 39 million adults and children in the United States.

Chronic migraine headaches can be debilitating, and often have a significant impact on quality of life. First-line preventive therapies, or prophylaxis, can help reduce the frequency and severity of these headaches.

In this article, we explore the most common treatment options for migraine prophylaxis, including what the research says about how effective these options are for preventing chronic migraine.

Angiotensin blockers are medications that prevent the production or uptake of angiotensin, a hormone that causes the blood vessels to narrow. Angiotensin blockers may include angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs).

Effectiveness

In one study, an ARB called candesartan was shown to reduce not only the number of headache days, but also headache hours, migraine days, and migraine hours, compared to placebo. In another study, an ACE inhibitor called lisinopril showed significant reductions in headache hours, headache days, and migraine days in study participants.

Side effects

Common side effects of angiotensin blockers may include cough, dizziness, fatigue, lightheadedness, gastrointestinal symptoms, and more. As migraine prophylaxis, it can take weeks for ACE inhibitors and ARBs to show long-term benefits.

Anticonvulsant drugs, also known as antiepileptic drugs (AEDs), are medications that help treat and prevent epileptic seizures by slowing nerve signals in the brain. Anticonvulsant drugs may include narrow-spectrum AEDs for specific types of seizures, or broad-spectrum AEDs for multiple seizures.

Effectiveness

Divalproex sodium and sodium valproate both showed effectiveness for reducing migraine headache rate in clinical studies. Topiramate was also found to significantly reduce migraine frequency in 11 different studies. Gabapentin, lamotrigine, and oxcarbazepine have shown mixed results in their effectiveness for migraine prophylaxis.

Side effects

Common side effects of AEDs may include rash, fatigue, increased energy, gastrointestinal symptoms, paresthesia, weight gain, and hair loss, among others. Anticonvulsants typically begin working immediately, but for migraine prophylaxis it can take 4 to 8 weeks to see results.

Antidepressants are medications that treat depression, anxiety, and other mental health conditions by altering the neurotransmitters in the brain. Antidepressant medications commonly include selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs), as well as other medications.

Effectiveness

In an early study, an SSRI called fluoxetine was shown to significantly reduce monthly migraine headache hours. Another study on an SNRI called venlafaxine demonstrated a significant reduction in average headache days for study participants. Amitriptyline, a tricyclic antidepressant, was also found to be effective for migraine prophylaxis.

Side effects

Common side effects of antidepressants may include nausea, vomiting, drowsiness, dry mouth, difficulty concentrating, increased heart rate, and more. As a preventive medication for migraine headaches, antidepressants can take 4 to 6 weeks or more to show benefits.

Beta-blockers are medications that reduce heart rate and blood pressure by blocking the actions of the hormone adrenaline (epinephrine). Beta-blockers, which can be nonselective, cardioselective, or third generation, are the most commonly prescribed medication for migraine prophylaxis.

Effectiveness

Multiple studies have found metoprolol to be effective for reducing migraine frequency by as much as 50 percent. A study on propranolol also found this medication to be effective in reducing migraine frequency, duration, and severity. Other potential beta-blockers for migraine prevention include timolol and atenolol.

Side effects

Common side effects of beta-blockers may include dry mouth, drowsiness, fatigue, weight gain, sleep disturbances, and more. Beta-blockers can take months to show effectiveness as a preventive medication for chronic migraine.

Botox, or botulinum toxin type A, is an injectable drug produced by the bacterium Clostridium botulinum, which temporarily weakens or paralyzes the muscles. While Botox is most commonly used for cosmetic purposes, it can also be used to treat certain medical conditions, such as chronic migraine.

Effectiveness

In one systematic review, researchers analyzed the data from 28 trials on the effectiveness of Botox for migraine prevention. Studies included those comparing Botox to a placebo, as well as those comparing Botox to other prophylactic treatments. Results of the analysis found that Botox was able to reduce headache frequency by roughly 2 headaches per month.

Side effects

Common side effects of Botox may include injection site pain, eyelid drooping, muscle weakness, and neck pain, among others. As a prophylactic agent for migraine, Botox is most effective after 4 weeks, with most trials recording results after as long as 12 weeks.

Calcitonin gene-related peptide (CGRP) therapy utilizes monoclonal antibodies to reduce the inflammation and pain associated with chronic migraine headaches. Erenumab is the most common medication used for migraine prophylaxis, but other medication options are also available.

Effectiveness

In one large trial, researchers assigned over 900 study participants with chronic migraine with either 70 milligrams erenumab, 140 milligrams erenumab, or a placebo. Migraine symptoms were analyzed every 4 weeks for a period of 20 weeks to determine the effectiveness of erenumab in reducing migraine frequency. Results showed that erenumab was able to reduce migraine days by 50 percent or more when compared with placebo.

Side effects

Common side effects of CGRP may include injection site pain, frequent upper respiratory infections, gastrointestinal issues, fatigue, nausea, and more. CGRP generally shows results for migraine prevention within the first 2 months, with effectiveness becoming stronger over time.

Non-steroidal anti-inflammatory drugs (NSAIDs) are medications that help reduce inflammation and pain by blocking the production of prostaglandins. NSAIDs are most commonly used for the prevention of menstrual migraine, or migraine attacks that specifically occur with menstruation.

Effectiveness

According to evidence-based guidelines from the American Academy of Neurology and the American Headache Society, NSAIDs show modest benefits for the prevention of migraine headaches. Naproxen sodium, flurbiprofen, ketoprofen, and mefenamic acid have all demonstrated benefits in clinical trials. However, long-term, daily use of NSAIDs is not always recommended for migraine prophylaxis, as it can lead to medication overuse headaches.

Side effects

Common side effects of NSAIDs may include gastrointestinal symptoms, headaches, drowsiness, dizziness, and in some cases, organ damage. As a preventive option for menstrual migraine attacks, NSAIDs should be taken 2 to 3 days before menstruation and during the first 2 to 3 days.

Triptans, also known as serotonin receptor agonists, are medications that help relieve inflammation by mimicking the actions of the neurotransmitter serotonin. Like NSAIDs, triptans are more suitable for short-term applications, such as menstrual migraine prophylaxis.

Effectiveness

In a study from 2008, frovatriptan was found to be effective at reducing migraine frequency in study participants. Another study found that naratriptan was effective at reducing menstrual migraine attacks when taken 2 days before menstruation and 3 days during. Zolmitriptan was also found to be effective at reducing the frequency of migraine attacks according to 2014 study.

Side effects

Common side effects of triptans may include headache, dizziness, nausea, and fatigue, among other symptoms. When used for migraine prophylaxis, triptans can show effectiveness for migraine symptoms and prevention in a matter of hours.

In addition to the medication options discussed above, certain vitamin and herbal supplements may also offer benefits for migraine prevention. These include:

  • coQ10
  • butterbur
  • feverfew
  • magnesium
  • melatonin
  • vitamin B2
  • vitamin B12
  • vitamin D

Effectiveness

According to the research, butterbur is the most effective herbal supplement for reducing frequency and severity of migraine attacks. In addition, feverfew, magnesium, and riboflavin have shown effectiveness for migraine prophylaxis in research studies. Additional supplements, such as coQ10, may be effective but more research is needed.

Side effects

Vitamin supplements don’t commonly cause side effects if they’re taken as directed and they’re not interacting with another medication you may be taking or a health condition you may have. That said, you should always talk with a doctor before taking any kind of supplements.

Vitamin supplementPossible side effects
coQ10mild insomnia or digestive upsets
butterburgas, headache, itchy eyes, diarrhea, breathing difficulties, fatigue, upset stomach, drowsiness
feverfewnausea, digestive problems, bloating; people sensitive to ragweed may experience allergic reactions
magnesiumloose stools, stomach upset, nausea (people with kidney issues are at a higher risk of experiencing side effects)
melatonindrowsiness, dizziness, headache and nausea
vitamin B2high doses may cause itchiness, numbness, burning/prickly sensations, orange urine, sensitivity to light
vitamin B12mild diarrhea, itching skin rash, headache, dizziness, nausea vomiting
vitamin Dexcessive amounts (over the daily recommended dose) may lead to hypercalcemia, a condition in which you have too much calcium in your blood. Symptoms of hypercalcemia include headaches, fatigue, excessive thirst, excessive urination, nausea, vomiting, decreased appetite.

Choosing the right treatment option for migraine prophylaxis is often a matter of trial and error, which can be difficult and frustrating, especially when your quality of life is negatively impacted by chronic migraine. However, your doctor will work closely with you to help find the medication that will work for you.

Generally, preventive medications are started at a low dose and adjusted up to a higher dose over time. Most medications for migraine prophylaxis can take anywhere from 2 to 3 months to see full results, with the best results after about 6 months.

Ultimately, the goal of migraine prophylaxis is a 50 percent reduction in migraine frequency over a full year.

Migraine prevention often involves more than just preventive medications. Lifestyle changes can also play an important part of preventing recurring migraine. Here are some best practices for preventing chronic migraine:

  • Keep a diary of known triggers. Creating a headache diary is an important step in being able to identify and avoid your migraine triggers. Consider trying a migraine app for tracking migraine triggers and patterns.
  • Consider alternative therapies. Alternative treatment options for migraine, such as acupuncture or acupressure, may provide additional symptom relief.
  • Practice good sleep hygiene. Poor sleep is one of the most common triggers for migraine, so practicing good sleep hygiene plays a crucial role in migraine prevention.
  • Engage in regular exercise. Research has shown that gentle exercise practices, such as yoga, may help reduce the frequency and severity of chronic migraine.
  • Prioritize relaxation. Stress is another known trigger for people with recurrent migraine attacks, so stress management skills are an important tool for prevention.
  • Treat migraine attacks as soon as possible. Migraine prophylaxis doesn’t mean that you’ll never have another migraine, so it’s important to keep emergency medication on hand for when migraine attacks inevitable develop.

As always, you should work closely with a doctor to create a migraine prevention plan that works for you.

Migraine prophylaxis is one the most important treatment approaches for reducing the frequency of recurrent migraine headaches.

Preventive treatment options for migraine include medications such as antidepressants, anticonvulsants, beta-blockers, and more. In addition to medication options, lifestyle changes also play an important role in migraine prophylaxis.

If you’ve been dealing with chronic migraine headaches that have significantly decreased your quality of life, talk with a doctor about which preventive treatment options are available to you.