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Migraine prophylaxis or migraine prevention refers to the chronic treatment of patients in order to prevent the development of a migraine headache from occurring.  Most patients with recurrent headaches that are frequent and disabling have migraine headaches. Therefore recurrent headache treatment usually includes taking a daily medication but this is not always the case. Most neurologists would agree that patients who have two (2) or more headaches (of any type) a week should be placed on a preventative to decrease the risk of their headaches becoming rebound. 

Rebound headache is a type of daily headache which occurs from the overuse of pain medications and is much more difficult to treat than frequent sporadic migraines.  The use of prophylaxis in patients having fewer than two headaches a week is common and depends upon headache frequency, the severity of the headache, the length of the individual headache, and the response to acute headache therapy. In some patients having even one or two disabling headaches each month is enough to justify migraine prevention. Basically the patient and physician have to decide it is beneficial for the patient to take a preventative rather than to just treat the migraine when it occurs.

There is no official diagnosis of cluster migraine headache. You either have I.H.S. cluster headache or I.H.S. migraine headache.{Cephalgia 2004;24 (Suppl 1)} On a rare occasion, it may be difficult to determine if a patient's headaches are migraines or cluster. In my experience, most patients using the terms "cluster migraine," "cluster migraines," or "cluster migraine headaches" have frequent migraine headaches that cluster together in time. The term, "cluster migraine", should be avoided to prevent confusion with the diagnosis of cluster headache.

Before choosing any preventative, it is important to eliminate frequent headache triggers. For many patients, the most common triggers include irregular sleep, missed meals, caffeine, and chocolate. Dr. Loftus does not believe in looking at individual foods as triggers until the headaches are relatively sporadic. Some other common triggers are menstrual cycles, weather fronts, and stress releases but these cannot be prevented.

Once the above preventative measures are being followed, the next most important step is to make sure the patient is not potentially having rebound headaches. Any medication that is being taken twice or more weekly could potentially be causing rebound headaches however; rebound headache causing medications are typically taken on a near daily basis. No migraine prevention program will be successful if the patient continues to take a rebounding medication.

How Can I Help My Doctor Help Me

You need to gather real time information on your headaches. Your physician needs the number of headaches, medication usage, and disability. It is also helpful to have your headaches properly classified. Dr. Loftus designed the iPhone and iPod touch app iHeadache to do all of this for you. The value of iHeadache is that it will produce reports that you and your physician will be able to use to properly diagnose your headache, determine if prevention is warranted, and to determine over time if therapy is working.

The next step is to choose a migraine prevention medication. Fortunately there are many choices. In general, the selections process initially begins with one of the highly effective migraine preventatives and then moves to less proven or less robust agents when the better agents are either not successful, not tolerated, or have side effects that makes patients want to avoid them completely. Dr. Loftus calls this method “intelligent trial and error.” Four agents that all neurologists will agree are well proven and highly effective are Elavil® (amitriptylene), Inderal®, (propranolo) Depakote® (valproic acid), and Topamax® (topiramate).

Elavil® (amitriptylene)

The primary advantage of Amitriptylene or Elavil® is that it is the cheapest preventative available. The monthly cost can literally be $5 per month. Unfortunately, the medication has a high percentage of side effects. Dry mouth, sedation, constipation, and weight gain are typically limiting side effects.

Inderal® (propranolol)

The next oldest, well established preventative is propranolol or Inderal®. This medication can worsen asthma, makes patients fatigue, and limit aerobic exercise but in general is fairly well tolerated. It is relatively inexpensive as well with a twice-daily generic form running about $40 per month. It is generally thought of as a weight neutral medication but all patients should be monitored for weight.

Topamax® (topiramate)

A third preventative is topiramate or Topamax®. This medication, first licensed as an antiepileptic medication, is the most popular medication currently prescribed by neurologists for headache prevention. While not more effective than the other first line agents, it is the only one that is clearly associated with weight loss. The average obese patient can expect to lose about 10% of their body weight over one year. Since obesity is a risk factor for frequent migraines over time, a large number of migraine patients who need preventatives are medically overweight or obese. Unfortunately topiramate does have a lot of side effects. Some side effects are more of a nuisance. Carbonated drinks taste badly while taking this drug and some patients experience tingling around the mouth, finger, or toes. Renal or kidney stones occur about 1% of the time and is the only side effect which does not go away when topiramate is discontinued without additional therapy. A small percentage of patients have an altered ability to think on the medication that commonly expressed as a word finding problem. This returns to normal with reduction or discontinuation of the medication. Finally there is a very rare condition of acute narrow angle glaucoma that is very painful but again resolves with discontinuation of the medication and specific medical therapy.

Depakote ER® or valproic acid

The last of the big four preventatives is valproic acid. The most convenient form for patients is Depakote ER® which is a once daily migraine prevention agent. Depakote ER® can cause birth defects and therefore, Dr. Loftus generally will not prescribe it to women who could become pregnant. In addition, valproic acid can cause weight gain and liver enzyme problems. Despite these warnings, the medication is generally well tolerated and can be used quite safely. However, given the issue with birth defects it is most commonly prescribed to males with migraines who are not overweight. Valproic acid is also widely used as an anticonvulsant.

Effexor XR® (venlafaxine)

Another well proven agent that is not widely used for migraine prevention is the antidepressant venlafaxine or Effexor XR®. Doses of 150 mg or more of this medication have been demonstrated to be a rather robust migraine agent. This medication can have side effects of nausea, sexual dysfunction and sometimes will increase blood pressure. The medication is thought to prevent migraine but its relatively balanced effect of serotonin and norepinephrine reuptake in the brain is similar to amitriptylene. However, unlike amitriptylene, the medication at these doses do not bind to other receptors and are therefore a selective serotonin and norepinephrine reuptake inhibitor (or SSNRI).

Cymbalta® (duloxetine)

Another SSNRI on the market is duloxetine or Cymbalta®. It is relatively more balanced than Effexor® and therefore is easier to titrate. It does cause the same amount of nausea as Effexor but is associated with less sexual dysfunction and less hypertension. To date, there are no double blind studies proving its effectiveness in migraine prevention. Cymbalta is FDA approved in depression, anxiety, and diabetic neuropathic pain. Since 33% to 66% of patients with chronic migraine also have depression, the use of Cymbalta® as a first line agent makes sense and is FDA approved for their depression.

Verapamil, Coenzyme Q10, Botox® and PFO

There are studies demonstrating verapamil to be a good anti-migraine agent although not as robust as the medications previously mentioned. Coenzyme Q10, which is available over the counter, was demonstrated in one small placebo controlled trial to be beneficial. The data on botulinum toxin type A or Botox® is quite extensive. Despite this, there continues to be a lot of controversy over its use. It does appear to help some patients with frequent migraines but it remains to be seen how best to choose which patients to treat with Botox®. The cost of the medication is also quite substantial.

There has been a lot of interest in the closing of a patent foramen ovale or PFO (a small channel between the right atria and left atria) of the heart for the prevention of migraines. Certainly patients with migraines have an increased risk of PFOs and their PFOs tend to be larger. There is some open label data that to suggest closing this hole or channel lessens the incidence of migraine. Bellaire Neurology is participating in the double blind ESCAPE Trial to test this theory.

The most important thing to remember is that there are numerous agents that one can try for migraine prevention. It is most likely that at least one of them will work well for you. Unfortunately prevention therapies are underutilized, resulting in excessive disability for migraine patients. If you are having frequent headaches, please see your neurologist and ask to be placed on prevention.