You need to take the medicine every day.
Who should take a medicine to prevent migraine attacks?
There is no definite rule. For example, you may wish to consider this option if you have:
- More than two migraine attacks (episodes) per month that cause significant disruption to your life.
- Less frequent, but severe, migraine attacks.
- The need to use a lot of painkillers or triptan medicines to treat migraine attacks.
- Painkillers or triptans for migraine attacks not working very well, or you are unable to take them because of side-effects or other problems.
- Migraine attacks, which are suspected of causing medication-induced headache. (You can read more about this in the treatment section of this leaflet. See also separate leaflet called Medication-induced (Medication-overuse) Headache which has further details).
- Menstrual migraine (see below)
Before embarking on preventative treatment, it is probably best to keep a migraine diary for a few months to assess:
- How often and how bad your migraine attacks are.
- Your current use of medication to treat the migraine attacks.
This may help you to decide if preventative treatment is worth a try, and also to help assess if you may have medication-induced headache. See separate leaflet called Migraine Trigger Diary, including a migraine diary that you may like to print out and use.
Which medicines are used to prevent migraine attacks?
Beta-blockers include propranolol, atenolol, metoprolol, timolol and nadolol. They are commonly used to treat conditions such as angina and high blood pressure. It was first noticed by chance that some people who were treated for angina, who also had migraine, found their migraine attacks (episodes) lessened when on propranolol. It is not clear how they work to prevent migraine. However, beta-blockers are now a common treatment for migraine - most commonly, propranolol. A low dose may work, but the dose can be increased if necessary. Some people cannot take beta-blockers - for example, some people with asthma or peripheral arterial disease.
Medicines called sodium valproate and topiramate are sometimes used. These are classed as anticonvulsants, and are usually used to prevent seizures of epilepsy. However, it was found that they can also prevent migraine attacks.
Amitriptyline is classed as a tricyclic antidepressant. However, it has an anti-migraine action separate to its antidepressant effect. It is not clear how it works for migraine. A low dose is started at first, and can be increased if necessary. Some people cannot take amitriptyline - for example, people who have had a heart attack (myocardial infarction), or have coronary heart disease, arrhythmia, or epilepsy. Note: strictly speaking, amitriptyline is not licensed for preventing migraine. However, in practice, it is commonly used, and many doctors are happy to prescribe it for this purpose.
This medicine is classed as a calcium-channel blocker. It is used quite a lot in many countries as a medicine to prevent migraine. However, flunarizine is not marketed and is not licensed in the UK. Despite this, it is sometimes specially imported from abroad under the direction of a headache specialist when it is considered worthwhile to try.
Various other medicines have been used for the prevention of migraine attacks. Most have limited evidence regarding their effectiveness or have potentially serious side-effects. However, if all else has failed, a specialist may suggest that you try out one of these. They include pizotifen, gabapentin, calcium-channel blockers, lisinopril, and selective serotonin reuptake inhibitors (SSRIs).
Some points about medicines to prevent migraine attacks
- You need to take the medicine every day.
- It is unlikely to stop migraine attacks (episodes) completely. However, the number and severity of attacks are often much reduced by a preventative medicine. It is useful for you to keep a migraine diary to monitor how well a medicine is working.
- It may take 1-3 months for maximum benefit. Therefore, if it does not seem to work at first, do persevere for a while before giving up.
- It is common practice to take one of these medicines for 4-6 months. After this, it is common to stop it to see if it is still needed. It can be restarted again if necessary.
- If a migraine attack occurs, you can still take painkillers or a triptan in addition to the preventative medicine.
- It is worth trying a different medicine if the first one you try does not help.
- Read the leaflet in the medicine packet for a list of cautions and possible side-effects.
What are the treatment options to prevent menstrual migraine?
Some women have severe menstrual migraine attacks (episodes), and some of those women find that treating each attack when it comes is not very satisfactory. In this situation, you may wish to consider a treatment that aims to prevent the migraine attacks. Migraine prevention treatments do not completely prevent all migraine attacks but they can make them less frequent and less severe. It may be useful to continue your migraine diary to compare before and after treatment.
These include mefenamic acid, naproxen, ibuprofen and diclofenac. These are painkillers which can be used to treat each migraine attack once it occurs. However, one option is to take a short course of one of these medicines for a few days each time you have a period, even if you don't have a migraine, in order to prevent an attack. You can start taking the tablets a few days prior to an expected period, or when the period starts, and take them until the last day of bleeding. (Anti-inflammatory painkillers are also used to treat period pain and heavy periods. Therefore, this may be a particularly good option if you also have painful or heavy periods.)
Some people cannot take anti-inflammatory painkillers - for example, people with a duodenal ulcer, and some people with asthma. Side-effects are uncommon if you take an anti-inflammatory painkiller for just a few days at a time, during each period. However, read the leaflet that comes with the tablets for a full list of possible cautions and side-effects.
Topping up your level of oestrogen just before and during a period can prevent menstrual migraine by preventing the sudden drop in oestrogen levels that trigger it. Oestrogen skin patches or gels are sometimes used. You put the patches or gel on your skin for seven days starting from three days before the expected first day of your period. The oestrogen is absorbed through the skin into the bloodstream. This is like having hormone replacement therapy (HRT) just for seven days each month. (Unlike long-term HRT you do not need an additional progestogen medicine with the oestrogen.) Note: oestrogen supplements are not licensed for the treatment of menstrual migraine. However, many doctors are happy to prescribe them 'off licence' for this condition.
Contraceptives as a treatment for menstrual migraine
Hormonal contraceptives are a useful option if menstrual migraine is a problem and you also need contraception. Options may include:
Progestogen-based contraceptives to prevent ovulation (if ovulation is prevented then your hormone cycle is altered and becomes more level, with no drop in the oestrogen level to trigger a migraine attack).
- These include desogestrel (a progestogen-only pill (POP) - Cerazette®), the contraceptive implant (Nexplanon®), or the contraceptive injection.
- Most women with migraine at any age can use progestogen-based contraceptives - even if they have migraine attacks with aura.
- The only time you would not be advised to use progestogen-based contraception is if you started to develop migraine attacks with aura only after starting to take one of these types of contraceptive.
Combined hormonal contraceptives (the COC pill, the contraceptive vaginal ring and the contraceptive patch) also prevent ovulation; however, during the pill-free week some women with menstrual migraine will still experience their headaches. Moreover, not all women with menstrual migraine can take these treatments.
- If you have or develop migraine attacks with aura, you should never use combined hormonal contraception again at all.
- If you have migraine attacks without aura you should not use combined hormonal contraception again if you are aged 35 or older. See main Migraine page for more information about migraines with and without aura.
In some women with migraine who use combined hormonal contraceptives, migraine attacks (episodes) are also triggered by the drop in the blood level of oestrogen during the pill-free or patch-free interval.
- So long as these migraine attacks are without aura AND you were already known to have migraine without aura before starting the pill or the patch, there is usually no need to stop your combined hormonal contraceptive unless you wish to try a different method.
- If they are migraines with aura you should stop using combined hormonal contraception.
- If you have never had migraines of any sort before, you should stop using combined hormonal contraception.
If you chose a combined hormonal contraceptive (pill, ring or patch) in the hope of reducing menstrual migraine but still have migraine attacks without aura in the pill-free week then options to consider to reduce migraine in the pill-free week are:
- Changing to a COC pill with less progestogen. Migraine attacks during the pill-free interval seem to occur less often in women who take a pill with a lower dose of progestogen.
- Tri-cycling your combined hormonal contraceptive. This means using your combined hormonal contraceptive continuously for three packets, rings or patches without any breaks, followed by a seven-day contraceptive-free interval. This keeps the level of oestrogen constant for nine weeks (three weeks each):
- By doing this you have fewer withdrawal bleeds and, therefore, fewer migraine attacks. It is OK to have only one withdrawal bleed every three packets. Note: you can only do this with pill types that have the same dose of progestogen for each dose. These are the commonly used types; however, check with your doctor or nurse if you are unsure.
- Using oestrogen supplements during the seven-day pill-free, ring-free or patch-free interval.
- A change to a different method of contraception.
Medicines plus behavioural therapy
An interesting research study published in 2010 compared two groups of people who had frequent migraines. One group took a beta-blocker medicine alone. Another group took a beta-blocker but also had a course of behavioural migraine management (BMM). BMM included education about migraine, helping to identify and manage migraine triggers, relaxation techniques and stress management. After a number of months the group of people who took the beta-blocker plus BMM had, on average, significantly fewer migraines compared with the group who took beta-blockers alone. Further research is needed to confirm this and to look at BMM combined with other medicines to prevent migraine.
Botulinum toxin (Botox®) injections to prevent migraine
In July 2010 the Medicines and Healthcare products Regulatory Agency (MHRA) licensed the use of botulinum toxin injections for the prevention of migraine. This decision was based on research studies that seemed to show it to be an effective treatment at reducing the number of migraine attacks (episodes).
Treatment consists of up to five courses of treatment with botulinum toxin injections every 12 weeks. The injections are given into muscles around the head and neck. It is not clear how this treatment may work for migraine. Botulinum toxin relaxes muscles but it may also have some sort of action to block pain signals. The theory is that these actions may have an effect of stopping a migraine headache from being triggered.
In 2012, guidelines were issued by the National Institute for Health and Care Excellence (NICE) on this treatment. NICE recommends botulinum toxin type A as a possible treatment for preventing headaches in some adults with persistent (chronic) migraine. The criteria set down by NICE for people who may be considered for this treatment are:
- If you have chronic migraine (that is, you have headaches on at least 15 days each month, with migraine on at least eight of these days); and
- You have already tried at least three different medicine treatments to prevent your chronic migraine headaches, but these have not worked; and
- You are not taking too many painkillers or using them too often.
Also, treatment should be stopped if:
- The number of days you have a chronic migraine headache each month hasn't reduced by at least 30% after two courses of botulinum toxin type A treatment; or
- Your chronic migraine changes to episodic migraine (that is, you have fewer than 15 days with headaches each month) for three months in a row.
Note: botulinum toxin injections are also used for cosmetic purposes - for example, as a treatment to smooth out wrinkles. However, for the treatment of migraine the injections need to be in specific sites around the head and neck muscles. Therefore, to prevent migraine attacks, it should only be administered by people trained in its use for this purpose.
How to use the Yellow Card Scheme
If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at www.mhra.gov.uk/yellowcard.
The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:
- The side-effect.
- The name of the medicine which you think caused it.
- The person who had the side-effect.
- Your contact details as the reporter of the side-effect.
It is helpful if you have your medication - and/or the leaflet that came with it - with you while you fill out the report.
Further reading and references
Migraine; NICE CKS, August 2017 (UK access only)
Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache; British Association for the Study of Headache (BASH) Guidelines, (2010 - reviewed 2014)
Carod-Artal FJ; Tackling chronic migraine: current perspectives. J Pain Res. 2014 Apr 87:185-94. doi: 10.2147/JPR.S61819. eCollection 2014.
The International Classification of Headache Disorders, 3rd edition (beta version).; The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul33(9):629-808. doi: 10.1177/0333102413485658.
Botulinum toxin type A for the prevention of headaches in adults with chronic migraine; NICE Technology Appraisal Guidance, June 2012
Headaches in over 12s: diagnosis and management; NICE Clinical Guideline (September 2012)
Derry CJ, Derry S, Moore RA; Sumatriptan (all routes of administration) for acute migraine attacks in adults - overview of Cochrane reviews. Cochrane Database Syst Rev. 2014 May 285:CD009108. doi: 10.1002/14651858.CD009108.pub2.
UK Medical Eligibility Criteria Summary Table for intrauterine and hormonal contraception; Faculty of Sexual and Reproductive Healthcare, 2016
Furman JM, Balaban CD; Vestibular migraine. Ann N Y Acad Sci. 2015 Apr1343:90-6. doi: 10.1111/nyas.12645. Epub 2015 Feb 26.
Schwedt TJ; Chronic migraine. BMJ. 2014 Mar 24348:g1416. doi: 10.1136/bmj.g1416.
Spigt M, Weerkamp N, Troost J, et al; A randomized trial on the effects of regular water intake in patients with recurrent headaches. Fam Pract. 2012 Aug29(4):370-5. doi: 10.1093/fampra/cmr112. Epub 2011 Nov 23.
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