Migraines: Stop them before they start

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In her compelling essay, "In Bed," novelist Joan Didion wrote, "That no one dies of migraine seems, to someone deep into an attack, an ambiguous blessing."

For many people, migraines are debilitating events. As Harvard Health editor Christine Junge wrote in this space last year about her battle with migraine:

"On the good days, the pain was just a mild throbbing sensation. Other times, there was a general sense of an ever-tightening pressure. On the days when I couldn't get out of bed, it felt like someone was tightening screws into the sides of my head and pounding a hammer above my left eye. The pain never went away, unless I was asleep."

Most migraine sufferers long to prevent these painful episodes. As I write in this month's Harvard Health Letter, about one-third of migraineurs could benefit from taking a preventive pill. But only a minority of them actually take advantage of this option. New treatment guidelines from the American Academy of Neurology and the American Headache Society profile the best preventive medications, and an herbal preparation, for migraine.

"These drugs can reduce the frequency and severity of migraine attacks, and may require different doses over time to achieve these benefits," says Dr. Lee H. Schwamm, vice chairman of the neurology department at Massachusetts General Hospital and professor of neurology at Harvard Medical School. "They must be taken daily. They are different from pain-relieving medicines—drugs that halt a migraine once it has started."

Pills for prevention

The guidelines include two categories of preventive medications. Those with proven effectiveness for preventing migraine include

• the antiseizure drugs divalproex (Depakote), valproate (Depacon), and topiramate (Topamax)
• the beta blockers metoprolol, propranolol, and timolol
• the triptan drug, frovatriptan (Frova), for short-term menstruation-associated migraine

Drugs that are probably effective include

• two antidepressants, amitriptyline (Elavil and others) and venlafaxine (Effexor)
• two other beta blockers, atenolol and nadolol
• two other triptans, naratriptan (Amerge) and zolmitriptan (Zomig)

The guidelines also include an herbal remedy made from butterbur, a plant in the daisy family. Butterbur contains chemicals called pyrrolizidine alkaloids (PA) that can damage the liver and cause other problems. If you want to use a butterbur-based treatment, choose a product that is certified as PA free.

Daily use, side effects may limit use

Since it's impossible to predict when a migraine will happen, these medications must be taken daily. But the more often you have to take a medicine, the less likely you are to take it faithfully. "If you don't have the symptom right away when you skip a dose, then you are even more likely to skip doses," says Dr. Schramm.

All medications, and herbal remedies, have the potential to cause side effects, cautions Dr. Schwamm. Antiseizure medicines can reduce concentration and may cause drowsiness. Beta blockers can slow the heart rate and sometime cause depression or sexual dysfunction. "Topiramate can cause weight loss, so some patients are more compliant with this drug," says Dr. Schramm.

Personalizing prevention

Migraine prevention doesn't necessarily require medication. Getting enough sleep, reducing stress, and paying attention to diet and exercise can help. So can identifying whether you have any migraine triggers, like chocolate, caffeine, or alcohol. Keeping a migraine diary that includes your stress level, what you've eaten and drunk, and the like can help identify triggers.

Tell us your story

Do you live with migraines? If so, let us know what your migraine triggers are. If you've tried medications, herbal remedies, or other preventive efforts, please tell us if they worked for you.