Preventing Episodic Migraines: Medications and Strategies

Migraines. Just the word can send shivers down the spine of anyone who’s experienced them. But what if I told you there’s a way to prevent these debilitating headaches? For those suffering from episodic migraines, the quest for relief and less headache days often feels endless. But there’s hope. Let’s dive into the world of medications designed to prevent these unwelcome visitors known as migraine attacks.

· CGRP Antagonists (Calcitonin Gene-Related Peptide Antagonists)

Ever heard of CGRP Antagonists for migraine prevention? No? Well, they’re a game-changer for many dealing with episodic migraines. They are also known as CGRP inhibitors. Placebo-controlled clinical trials have shown these medications to be some of the most effective for migraine prevention. Think of them as the body’s little soldiers, specifically trained to tackle migraines. Their mission? To block a protein called CGRP. This protein plays a sneaky role in transmitting pain from those pesky migraine-inducing trigeminal nerve fibers in our faces and heads.

Now, the FDA has given a thumbs up to a few of these preventive medications designed PURELY for the prevention of migraine headaches. The first class of CGRP antagonists are called the CGRP monoclonal antibodies. There are 4 types and they include Aimovig, Ajovy, Vyepti, and Emgality. These are administered by monthly self-injections, quarterly self-injections, or quarterly IV infusions. The best part? Their side effects are generally mild to none. So for many, an injection is a small price to pay for relief from episodic migraines.

The second class of CGRP antagonists are called the gepants. There are 2 types that are FDA approved for migraine prevention and include Rimegepant (Nurtec ODT) and Atogepant (Qulipta). These are administed in pill form. Nurtec ODT is a quickly dissolving tablet in the mouth, taken every other day. The bonus is that Nurtec ODT is the only migraine medicine which is actually dually approved for both episodic migraine prevention, as well as for abortive/acute (as needed) use. Qulipta is a once daily pill which is also unique in that it is FDA approved for prevention of both episodic migraine (1-14 days per month), and chronic migraine (15-30 days per month).

· Beta-Blockers

Switching gears, let’s talk about beta-blockers. Originally designed (and still used) to treat high blood pressure and irregular heart rhythms, these medications have found a second calling in preventing episodic migraines. How do they work? By keeping those blood vessels in check and calming our nervous system electrically. It’s like giving your body a gentle reminder to relax and not overreact.

Among the top performers in this category are Metoprolol (Toprol) and Propranolol (Inderal; also FDA approved for migraine prevention). But remember, while they’re effective, they’re not for everyone. Some folks, especially those with asthma or low blood pressure, might need to steer clear. Always best to chat with a doctor before diving in.

Notably, the beta-blockers are not the only blood-pressure category that is used for migraine prevention though. Additional types which are also used and have preventive evidence (although not FDA approved for migraine prevention) include the ACE inhibitors (Lisinopril), calcium channel blockers (Verapamil), and Angiotensin Receptor Blockers (ARBs) (Candesartan, Losartan).

· Anticonvulsants

Now, here’s a twist. Some medications designed for epilepsy, a condition related to seizures, can actually help with preventing episodic migraines. However, it’s not too surprising since both migraine and seizures are caused by electrical events in the brain. It’s like discovering your favorite singer is also a fantastic actor. Two talents, one package. Scientists believe that migraines and epilepsy might share some brain functions, which is why anticonvulsants like Valproic acid (Depakote) and Topiramate (Topamax) can be effective against migraines. But, like all stars, they come with their quirks. Some people might experience adverse effects like weight changes, dizziness, mood changes, or cognitive and memory complaints. It’s all about finding what not only works for you, but also what you are tolerating.

· Antidepressants and Anti-Anxiety Medications

Last on our list are antidepressants and anti-anxiety medications. The most commonly used options include the tricyclic antidepressants (TCAs) Amitriptyline (Elavil), Nortriptyline (Pamelor), and the serotonin and norepinephrine reuptake inhibitors (SNRIs) Venlafaxine XR (Effexor XR), Duloxetine (Cymbalta), and Desvenlafaxine (Pristiq). While their primary role is to lift moods, they have a side gig in preventing episodic migraines for many patients. They work by managing brain chemicals (neurotransmitters), particularly serotonin and norepinephrine, making them potential allies against migraines. But, as with all medications, it’s essential to be aware of potential side effects.

Diving back into antidepressants, it’s fascinating how a medication primarily designed to elevate mood can be a secret weapon against episodic migraines. The science behind it? These medications affect mood by managing the brain chemicals serotonin and norepinephrine. This action can be a game-changer for many suffering from episodic migraines. However, every silver lining has a cloud. Some users might experience side effects like nausea, changes in appetite, weight changes, or even negative mood changes. It’s always a balance between benefits and potential drawbacks.

Non-Medicine Migraine Preventive Treatments

Some patients prefer to try non-medicine preventive treatments for migraine. There are a variety of options. Natural treatments such as vitamins and supplements are commonly used, and I recommend them to most of my patients. Magnesium and Vitamin B2 (Riboflavin) are two of the most commonly used migraine preventive supplements, but there are many others. There are also neuromodulation devices which are FDA cleared for migraine prevention. Additional non-medicine migraine preventive strategies can include meditation, yoga, or relaxation techniques. All of these topics are discussed more in depth in other blogs, and are beyond the scope of today’s blog.

Migraine Preventive Treatments For Chronic Migraine

A quick word on chronic migraine. Today’s blog focused on episodic migraine prevention. Episodic migraine is when there are 1-14 migraine days per month on average. Chronic migraine is defined as 15-30 overall headache days per month, with at least 8 of those days having migrainous features. In general, all of the above discussed options are also used clinically to treat chronic migraine. An additional very common treatment which is FDA approved (since 2010) only for chronic migraine (not episodic migraine) is Botox injections (botulinum toxin) every 3 months. Qulipta (Atogepant) is the only once daily pill that is FDA approved for prevention of both episodic migraine as well as chronic migraine. The CGRP mAbs discussed above are commonly used for chronic migraine as well as episodic migraine also.

When Should You Start a Migraine Preventive Treatment?

In general, the decision of starting a preventive migraine treatment largely depends on migraine frequency as well as how much they impair your normal function. According to the American Headache Society and American Academy of Neurology, if someone is having 4 or more migraine attacks per month, preventive treatment of episodic migraine should be considered. That’s not a hard and fast rule though. If someone is having 1 per month but it is wiping them out with a week of missed work every month from a long attack, obviously there are more factors to take into account other than a simple number. I like to remind patients that the goal of preventive medicines is to decrease the frequency and/or severity of migraines, hopefully by 50% or more. Eventually, once they are doing consistently very well for at least 3-6 months, we then try to start getting rid of medicines again. Unfortunately, there is no cure for migraine, so make sure to not make that your expectation. Not that it can not happen, but it shouldn’t be the expectation. Regardless of preventive drugs, migraines still have the potential to come on anytime (usually at the least ideal times!).

In addition to starting a preventive migraine medication, everyone with migraine also must have an effective strategy for the acute treatment of migraine. This topic is discussed in other blogs I have written. What we know is that patients that do not have an effective migraine management plan with both an effective acute treatment and preventive treatment tend to gradually continue to worsen in terms of migraine frequency and severity.

A Message from Virtual Headache Specialist

The journey through episodic migraines can often feel like a maze. But remember, you’re not walking this path alone. At Virtual Headache Specialist, we stand beside you, offering guidance and expertise. Our dedicated team is passionate about helping you navigate your options, ensuring you get a treatment plan that’s just right for you. Because while medications are a valuable tool, a personalized approach is the key to unlocking relief.

The Horizon of Migraine Treatments

The world of migraine treatments is in constant flux, with discoveries and innovations emerging regularly. Can you imagine a future where episodic migraines are merely tales of the past? We’re optimistic about what’s to come. For now, the focus remains on harnessing the power of current treatments, from CGRP Antagonists to Beta-Blockers, ensuring everyone finds their beacon of hope.

Empower Yourself Against Migraines With Virtual Headache Specialist

Are episodic migraines casting a shadow over your days? It’s time to step into the light. Armed with knowledge and the right support, you can pave the way to a life where migraines don’t hold the reins. And always remember, Virtual Headache Specialist is with you, cheering you on every step of your journey.