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Triggers for an individual's migraine headaches can sometimes be identified. Among the most common include chocolate, caffeine, menstrual cycles, weather changes, and sleep deprivation. One can sometimes identify preventable migraine triggers by carefully keeping a headache diary for a series of attacks and then identifying a common element. When this is unsuccessful, or when the triggers are not preventable, then migraine prophylaxis or migraine prevention has to be considered.

Migraine prophylaxis or migraine prevention refers to the chronic treatment of patients (usually, but not always taking daily medication), in order to prevent the development of a headache in the first place.  Most neurologists would agree that patients having 3 or more headaches (of any type) a week should be placed on prophylaxis 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 3 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.  Basically the patient and physician have to decide it benefits the patient to take a daily medication to prevent the sporadic migraine.

Many medications have been shown in open label trials to prevent migraines.  Fewer medications have been shown in placebo-controlled trials or head-to-head trials to prevent migraines.  The use of placebo-controlled trial is considered especially important because migraine frequency and intensity will frequently increase or decrease over time on its own.  Many medications that seemed successful in open label trials proved not to work in placebo controlled trials. Since patients would typically agree to try medication prevention during a time of increased frequency, it could be expected that some patients would spontaneously improve.  In addition, it is possible that the decision to do something for your migraines to prevent them or merely have them diagnosed as migraines and not a more serious disease may reduce them as well.  This is commonly referred to as the placebo effect.   The relative importance of the bias of the design of open-labeled trials versus the placebo effect has not been studied. 

Another form of bias affecting open labeled trials is what is known as a publishing bias.  Physicians and journals are more likely to publish studies with positive effects.  Therefore, if separate observers do four trials and only 1 shows a positive result, it is possible that only this result will be published.  In either case, the importance of a trial design to eliminate bias is essential.  Therefore, therapies shown to be effective only in open-labeled trials but not controlled trials, have to be viewed with a healthy degree of skepticism.

To help physicians treat patients, the US Headache Consortium published guidelines for the use of prophylactic treatment of migraines.  The US Headache Consortium includes representative from the American Academy of Neurology, American Academy of Family Physicians, American Headache Society, American College of Emergency Physicians, America College of Physicians, American Society of Internal Medicine, American Osteopathic Association, and the National Headache Foundations.  The medications were divided into five groups.  The first group consisted of medications with proven high efficacy and mild-moderate side effects.  Only a few medications made this list and they are Elavil® (amitriptyline), Inderal® (propranolol), Depakote® (valproic acid).

Soon to be added to this list is Topamax® (topiramate). The drug has been approved for migraine prevention by the FDA. The fact that this drug causes weight loss and many migraine prevention drugs cause weight gain, is making it very popular among those patients who are overweight.

Once a list is published, it has the potential to be out-of-date.  Because most of the medications in the first group can have undesirable side effects, physicians commonly have to use other migraine preventatives.  My current belief is that the most robust agents for migraine prevention at this time are inderal, Topiramate, Depakote, and elavil.

Other medications that can be tried include coenzyme Q10 and riboflavin. Coenzyme Q10 has been shown in at least one double blind placebo controlled trial to reduce the incidence of migraine. The trial by Dr. Sandor used 100mg three times daily. The success rate was comparable to the first line medications currently used. If replicated, it will definitely be considered a first line agent. One problem with supplements is the lack of manufacturing oversight. The company performing these studies claim that theor over the counter form is not the same as others. Despite this, I can report, some patients have done well on over the counter coenzyme Q10. Again, this represents a form of open trial with all of the problems mentioned above.

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.

Dr. Loftus periodically conducts acute migraine and migraine prevention trials. If you are willing to come to Houston, please put your name on the list and we will contact you when more information is available.

Acute Migraine Therapy