Preventative (prophylactic) medications may be taken daily to prevent or reduce
the frequency and severity of migraine attacks in the following
situations:
The more common types of medication used to prevent migraine are listed below.
Beta-blockers
Some, but not all, beta-blockers decrease the frequency of migraine attacks.Those that are effective include atenolol, metoprolol, nadolol and propranolol. Beta-blockers may act via the central catecholaminergic system and brainserotonin receptors. [25,26]
Tricyclic antidepressants
In migraine prophylaxis, tricyclic antidepressants such asamitriptyline are claimed to be especially useful for patients who also havetension-type headaches. The mechanism of action is thought to be unrelated totheir antidepressant activity. In migraine, tricyclic antidepressants act byinhibiting noradrenaline and serotonin uptake and attenuating beta-adrenergicand central serotonin receptor function. [73,74]
Anti-epileptics
Divalproex sodium, sodium valproate and valproic acid are effective for migraine prophylaxis. [73,74] In addition, study data suggest that topiramate may also be useful for migraine prophylaxis, although some patients experience side effects such as peripheral paraesthesias in the hands and feet. [73,74]
Calcium channel blockers
Calcium channel blockers have a gradual onset of action with therapeutic effects typically not seen until several weeks after the start of treatment for migraine prophylaxis. These agents are thought to exert their activity in migraine by preventing hypoxia and the cellular influx of calciumions. [73,74]
Methysergide
Methysergide (an ergotamine derivative) causes carotidvasoconstriction and inhibition of perivascular neuronal peptide release. It isindicated for severe recurrent migraine attacks that are unresponsive to othermedication, although treatment should be interrupted every 6 months for 1-2months to prevent retroperitoneal fibrosis. [74]
ACE inhibitors
ACE inhibitors have been shown to have a positive effect on the frequency and severity of migraine attacks. [75] The angiotensin converting enzyme(ACE) inhibitor lisinopril alters sympathetic activity, inhibits free radicalactivity, increases prostacyclin synthesis and blocks the degradation of bradykinin, encephalin and substance P. All these pharmacological effects have relevance in the pathophysiology of migraine. [73,76,77]
Angiotensin receptor blockers
Angiotensin receptor blockers also appear to reduce the frequency and severity of migraine. [75] Candesartan cilexetil hasdemonstrated effective migraine prophylaxis with few side effects. [73,78] Its mechanism of action as amigraine prophylactic is not yet known. However, the ability of candesartan to reduce the effects of angiotensin II (resulting in vasoconstriction, increased sympathetic discharge and adrenal medullary catecholamine release) may be involved.
- high migraine disability despite acute treatment
- treatment failure, contraindications or side effects of acute treatment
- overuse or potential overuse of acute medication
- complicated migraine, i.e. hemiplegic migraine [71,72]
- patients who experience four or more attacks per month [19,24]
- patients whose migraines are very predictable (e.g. associated with the menstrual cycle).
The more common types of medication used to prevent migraine are listed below.
Beta-blockers
Some, but not all, beta-blockers decrease the frequency of migraine attacks.Those that are effective include atenolol, metoprolol, nadolol and propranolol. Beta-blockers may act via the central catecholaminergic system and brainserotonin receptors. [25,26]
Tricyclic antidepressants
In migraine prophylaxis, tricyclic antidepressants such asamitriptyline are claimed to be especially useful for patients who also havetension-type headaches. The mechanism of action is thought to be unrelated totheir antidepressant activity. In migraine, tricyclic antidepressants act byinhibiting noradrenaline and serotonin uptake and attenuating beta-adrenergicand central serotonin receptor function. [73,74]
Anti-epileptics
Divalproex sodium, sodium valproate and valproic acid are effective for migraine prophylaxis. [73,74] In addition, study data suggest that topiramate may also be useful for migraine prophylaxis, although some patients experience side effects such as peripheral paraesthesias in the hands and feet. [73,74]
Calcium channel blockers
Calcium channel blockers have a gradual onset of action with therapeutic effects typically not seen until several weeks after the start of treatment for migraine prophylaxis. These agents are thought to exert their activity in migraine by preventing hypoxia and the cellular influx of calciumions. [73,74]
Methysergide
Methysergide (an ergotamine derivative) causes carotidvasoconstriction and inhibition of perivascular neuronal peptide release. It isindicated for severe recurrent migraine attacks that are unresponsive to othermedication, although treatment should be interrupted every 6 months for 1-2months to prevent retroperitoneal fibrosis. [74]
ACE inhibitors
ACE inhibitors have been shown to have a positive effect on the frequency and severity of migraine attacks. [75] The angiotensin converting enzyme(ACE) inhibitor lisinopril alters sympathetic activity, inhibits free radicalactivity, increases prostacyclin synthesis and blocks the degradation of bradykinin, encephalin and substance P. All these pharmacological effects have relevance in the pathophysiology of migraine. [73,76,77]
Angiotensin receptor blockers
Angiotensin receptor blockers also appear to reduce the frequency and severity of migraine. [75] Candesartan cilexetil hasdemonstrated effective migraine prophylaxis with few side effects. [73,78] Its mechanism of action as amigraine prophylactic is not yet known. However, the ability of candesartan to reduce the effects of angiotensin II (resulting in vasoconstriction, increased sympathetic discharge and adrenal medullary catecholamine release) may be involved.
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