The FDA's approved drugs for prevention of migraine are:
- Propanolol (Inderal, generic)
- Timolol (Blocadren, generic)
- Divalproex sodium (Depakote, generic)
- Valproate sodium (Depacon, generic)
- Valproic acid (Stavzor, Depakene, generic)
- Topiramate (Topamax, generic)
- OnabotulinumtoxinA (Botox)
- Erenumab (Aimovig)
- Fremanezumab (Ajovy)
- Galcanezumab (Emgality)
Propanolol and timolol are beta-blocker drugs. Divalproex, valproate, valproic acid, and topiramate are anti-seizure drugs. Erenumab, fremanezumbab, and galcanezumab are CGRP antagonists. Many other drugs are also being used or investigated for preventing migraines.
Beta-blockers are commonly prescribed to reduce high blood pressure. Some beta-blockers are also useful in reducing the frequency and severity of migraine attacks.
Propranolol (Inderal, generic) and timolol (Blocadren) are approved specifically for prevention of migraine. Metoprolol (Lopressor, generic) is also recommended. Atenolol (Tenormin, generic), and nadolol (Corgard, generic) are other options for migraine prevention.
Side effects of beta-blockers may include:
- Fatigue and lethargy
- Vivid dreams and nightmares
- Dizziness and light-headedness upon standing
- Reduced exercise capacity
- Coldness in legs, arms, feet, hands
- Gastrointestinal problems
If side effects occur, call your health care provider. Never abruptly stop taking a beta-blocker because this can increase the risk for dangerous heart rhythms, heart attack, or other heart problems. Some research suggests that people with migraines who have had a stroke should avoid beta-blockers.
Anti-seizure drugs, also called anticonvulsant medications, are commonly used for treating epilepsy and bipolar disorder.
Divalproex sodium (Depakote, Depakote ER, generic), valproic acid (Stavzor, Depakene, generic), and valproate sodium (Depacon, generic) are collectively referred to as valproate products. Topiramate (Topamax, generic) is another anti-seizure drug. Valproate products and topiramate are the only anti-seizure drugs that are approved for migraine prevention.
Anti-seizure medication side effects vary by drug but may include:
- Upset stomach
- Tingling sensation in arms and legs
- Difficulty concentrating
- Weight gain (or with topiramate, weight loss)
- Valproate and divalproex can cause serious side effects, such as pancreas inflammation (pancreatitis) and liver damage
- Birth defects
Pregnant women should never use valproate products to prevent migraine. When taken during pregnancy, these drugs can cause decreased IQ scores in children or can cause life-threatening malformations of the brain and spinal cord. Topiramate can also increase the risk for birth defects, particularly cleft palate. Women who are of childbearing age and considering pregnancy should discuss with their doctors other types of migraine-preventive medication.
All anti-seizure drugs can increase the risks of suicidal thoughts and behavior (suicidality). The highest risk of suicide can occur as soon as 1 week after beginning drug treatment, and can continue for at least 24 weeks. People who take these drugs should be monitored for signs of depression, changes in behavior, or suicidality.
Tricyclics and Other Antidepressants
Amitriptyline (Elavil, generic), a tricyclic antidepressant drug, has been used for many years for migraine prevention. It may work best for people who also have depression or insomnia. Tricyclics can have significant side effects, including disturbances in heart rhythms, and can be fatal when overdosed. Although other tricyclic antidepressants may have fewer side effects than amitriptyline, they do not appear to be as effective for migraine prevention.
Venlafaxine (Effexor, generic) is another antidepressant recommended for migraine prevention. It is a serotonin norepinephrine reuptake inhibitor (SNRI). Serotonin-reuptake inhibitors (SSRIs) such as fluoxetine (Prozac, generic) do not appear to be effective for migraine prevention.
OnabotulinumtoxinA (Botox) is approved for preventing chronic migraine in adults. Botox is given by multiple injections to the head and neck area about every 12 weeks. These injections may help to dull future headache symptoms. Botox appears to work best for chronic migraines. It has not been shown to work for migraines that occur less frequently than 14 days a month, or for other types of headaches (such as tension headaches). The most common side effects are neck pain and headache.
CGRP antagonists are a new class of drugs approved by the FDA in 2018 for the preventive treatment of migraine. These are monoclonal antibodies against a molecule called calcitonin gene-related peptide (CGRP) or against its receptor. CGRP is considered an important factor causing migraine pain by dilating blood vessels and increasing inflammation in the brain.
CGRP antagonists approved to date include erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality). They are used in patients with migraine with or without aura who cannot tolerate or did not respond to treatment with other drugs such as anti-seizure, antidepressant, or beta-blocker therapy. These drugs are administered by a monthly injection and have minimal side effects.
There are some safety concerns with these new drugs, including with pregnant women or children.
The FDA has approved a neurostimulation device for the prevention of migraine headaches. It is a small, portable, battery-powered device that uses transcutaneous electrical nerve stimulation (TENS) to stimulate the trigeminal nerve.
The device resembles a plastic headband and is placed across the forehead, where it delivers an electrical signal through an electrode placed on the skin. It is used once a day for 20 minutes. In studies, the device helped reduce migraine frequency and use of medication. It did not completely prevent migraines and did not reduce the intensity of migraines that did occur.
Side effects of neurostimulation devices are uncommon and include sleepiness, dizziness, and pain or discomfort at the application site.
Other Treatments for Preventing Migraines
Other types of medications and treatments are being used or investigated for prevention of migraines.
Frovatriptan is effective for prevention of menstrual migraines. Naratriptan (Amerge, generic) and zolmitriptan (Zomig) may also be helpful.
Certain over-the-counter and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful for migraine prevention. They include naproxen (Aleve, generic), ibuprofen (Aleve, Motrin, generic), fenoprofen (Nalpron), and ketoprofen (Nexcede, generic). However, daily use of NSAIDs can cause stomach problems and may also lead to a condition called medication overuse headache.
Commonly used for treating high blood pressure, angiotensin converting enzyme (ACE) inhibitors such as lisinopril (Prinivil, generic) block the production of the protein angiotensin, which constricts blood vessels and may be involved in migraine.
Angiotensin-receptor blockers (ARBs) such as candesartan (Atacand) are another type of high blood pressure medication being studied for migraine prevention.
Subcutaneous (under the skin) injections of histamine may be helpful for migraine prevention.
New types of nasal sprays and powders are being researched. Some of them use capsaicin, the chemical found in cayenne peppers, to help relieve pain.
Herbs and Dietary Supplements
Certain herbs and dietary supplements may be helpful for migraine prevention. See Lifestyle Changes section of this report.