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• Patients should understand all aspects relating to preventive management, such as when to take medications, when to call physician, keeping appointment, or notifying doctor when they feel they have achieved significant improvement
• Medication should be tapered slowly as the patient improves and should be reevaluated if headaches begin to recur.

First-line medications that are recommended by the U.S. Consortium on Headache guidelines for prevention include:

• Beta Blockers - propranolol (Inderal) and timolol (Blocadren) have been approved by the U.S. Food and Drug Administration for prevention for migraine headache. They are contraindicated in patients suffering from depression, for athletes due to reduced exercise tolerance, for patients with congestive heart failure, asthma, hypoglycemia, and hypotension. Adverse effects include:

  • Drowsiness
  • Sleep disorders
  • Depression
  • Memory disturbance
  • Hallucinations
  • Nightmares
  • Orthostatic hypotension (drop in blood pressure when changing positions, such as sitting to standing)
  • Bradycardia - slow heart beat

• Antidepressants - amitriptyline is the only tricyclic antidepressant (TCA) with consistent evidence of efficacy in headache prevention. Tricyclic antidepressants are best used for patients with depression or sleep disturbances. Another class of antidepressants, selective serotonin reuptake inhibitors (SSRIs), has fewer side effects but has not proven to be effective for prevention of headaches. If a patient cannot tolerate the side effects of amitriptyline, they can try a difference TCA to see if it is more tolerable. Side effects of TCAs include:

  • Drowsiness
  • Increased appetite and weight gain
  • Orthostatic hypotension

• Calcium Channel Blockers - studies support the efficacy of flunarizine but it is not available in the U.S. Verapamil (Bosoptin) is particularly well suited for people with comorbid conditions such as hypertension or people with other comorbid conditions for whom beta blockers are contraindicated, such as asthma. Calcium channel blockers also appear to be effective for people who experience prolonged aura with the migraine headaches. The most common side effect of verapamil is constipation.

• Anticonvulsant drugs - these include divalproex sodium (Depakote), and topiramate (Topamax), both of which have been approved by the FDA for prevention of migraine headache. Topiramate has been studied extensively. It is effective within two weeks of initiating treatment and the benefit increases for several months. Anticonvulsant drugs are particularly helpful for patients with a comorbid history of bipolar disorder, anxiety disorder, or epilepsy. Anticonvulsants have a high rate of adverse side effects and drug levels must be carefully monitored. Adverse effects include:

  • Sedation, hair loss, tremor, cognitive changes, hepatotoxicity, nausea/vomiting, and indigestion (valproate)
  • Weight loss, paresthesia, cognitive changes (topiramate)
  • Dizziness and drowsiness (gabapentin)
  • Interference with oral contraceptives (antiepileptic drugs)

The U.S. Consortium on Headache notes that there is fair evidence of effectiveness for prevention of migraines for the following medications::

• Gabapentin (Neurontin)
• Naproxen sodium (Anaprox)

• Botulinum Toxin A (Botox) injected into various point of the face and neck. Results of studies regarding efficacy are mixed and it is used by some physicians only after all other medications have failed. Side effects are mild and temporary and include:

  • Frontal facial weakness
  • Ptosis (drooped eyelids)
  • Pain at injection sites

Nonsteroidal anti-inflammatory drugs are helpful for preventing menstrual migraines if commenced several days before menstruation and continued for a few days after the period begins.