Is It Time to Consider Preventive Treatment for Migraine?

For many people with migraine, treatment starts with acute medicine — something you take when an attack begins to stop the attack from progressing or to make the pain and other symptoms less severe. But when attacks become more frequent and harder to control with acute treatment, it may be time to consider preventive treatment.

“The ultimate goal of preventive or maintenance treatment is more headache-free days,” says William Howell Jarrard, MD, a neurologist and assistant professor at the Medical University of South Carolina in Charleston. Preventive treatment can also make attacks less severe and make acute medicines work better, Dr. Jarrard says.

For many people, preventive medications can be a very effective part of a migraine treatment plan, says Jarrard. “These days, we have so many treatment options,” he says.

Acute treatment is what you take as soon as you feel a migraine attack starting, while preventive treatment is taken on a regular schedule to prevent attacks in the first place, says Joshua Tobin, MD, a neurologist at Banner Health in Phoenix, who specializes in headache and migraine.

“If people have frequent headache attacks or migraine attacks and they’re taking their as-needed medications — even over-the-counter drugs — too frequently, it can actually make their headaches worse over time and make them more frequent,” says Jarrard.

Preventive treatment is often underused, even among people who would likely benefit from it, says Jarrard.

Frequency is not the only thing that matters when deciding to add preventive treatment, however. “Even someone with fewer attacks may benefit from preventive drugs if those attacks are especially disruptive or hard to treat,” says Jarrard.

The same goes when acute treatment is falling short — adding a preventive drug may help, says Dr. Tobin.

The roster of preventive migraine treatments has a lot more variety than it did a few years ago. “The newer medications are truly game changers in our field,” says Jarrard. The best option — or options — for each person often depends on symptoms, other health conditions, and the overall response to the treatment.

Beta-Blockers These blood pressure drugs are thought to help steady the overactive nerve and blood vessel signaling involved in migraine. They include the following:

• propranolol (Inderal LA, InnoPran XL)
• metoprolol (Lopressor, Toprol-XL)
• timolol

Anticonvulsants These seizure medicines can help prevent migraine by dampening abnormal nerve excitability. They include the following:

• topiramate (Topamax, Qudexy XR, others)
• valproate

• Tricyclic Antidepressants (TCAs) These older antidepressants affect brain chemicals involved in pain signaling and are commonly used for migraine prevention, especially when sleep problems are also part of the picture. They include amitriptyline and nortriptyline; common side effects can include drowsiness, dry mouth, constipation, and weight gain.

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• Serotonin and Norepinephrine Reuptake Inhibitor (SNRI) The SNRIs venlafaxine (Effexor XR) and duloxetine (Cymbalta) work differently from TCAs and may be a good option for someone who also has depression or anxiety; possible side effects can include nausea and fatigue.

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While these older medications can be effective, the side effects — especially for TCAs — can be pretty unpleasant, says Jarrard.

The newer options were designed more specifically around the changes in the brain that lead to migraine.

CGRP Inhibitors (Monoclonal Antibodies) These drugs were developed specifically for migraine prevention. They block the protein CGRP or its receptor, interrupting a pathway strongly linked to migraine attacks. The following are in this class of drugs:

• erenumab-aooe (Aimovig)
• fremanezumab-vfrm (Ajovy)
• galcanezumab-gnlm (Emgality)
• eptinezumab-jjmr (Vyepti)

“CGRP is a substance that is released in large quantities on the surface of the brain at the start of a migraine,” says Tobin. The drugs do not stop CGRP from being released, but they block it from activating the pathway that helps trigger migraine.

Atogepant (Qulipta)
Atogepant is an oral gepant used only for prevention.

“We definitely feel extraordinarily comfortable with Botox, because it’s been approved by the U.S. Food and Drug Administration [FDA] for migraine for over 15 years,” says Jarrard.

Neuromodulation devices use electrical or magnetic stimulation rather than medication. They stimulate nerves to change how the brain processes pain. Therapies include transcutaneous supraorbital nerve stimulation, external vagal nerve stimulation, distal transcutaneous electrical stimulation, combined occipital and trigeminal neurostimulation, and single-pulse transcranial magnetic stimulation.

For prevention, FDA-cleared devices include the following:

• Cefaly
• Savi Dual
• GammaCore
• Nerivio
• HeadaTerm 2

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These devices can be appealing for people who want to avoid medication side effects or need a nondrug option. But in practice, access can be a major barrier.

“I tend to be cautious about neuromodulation, primarily due to cost considerations and the challenges that many patients face obtaining insurance coverage for these devices,” says Tobin. “While the clinical data certainly supports their effectiveness, the practical reality is that many patients can’t access them.”

No prevention treatment is likely to prevent all migraine attacks.

“Our ultimate goal is fewer migraine days, less disability, and more control,” says Jarrard, adding that preventive treatment can also make migraine attacks less severe and make rescue medicine work better.

How much relief a person gets depends on the treatment and the individual’s response to it. Evidence suggests that preventive medications often reduce monthly migraine days by about three or four days a month in clinical trials.

Bottom line: If your migraine attacks are bothering you and aren’t well managed with your acute medication, it’s a good idea to talk with your provider about preventive medications, says Jarrard.

• If migraine attacks are happening often, are especially disruptive, or are getting harder to control with acute medicine alone, it may be time to ask your doctor about preventive treatment.
• Preventive treatment does not stop every migraine attack, but it can lead to fewer migraine days, less severe attacks, and less need for acute medication.
• There are more options than there used to be, including newer CGRP-targeting therapies, Botox, and neuromodulation devices, so treatment can be tailored to each individual.