Introduction

In the past few years the use of prophylactic or preventive drug treatments has fallen. This could be because some prophylactics have side effects such as weight gain and can take time before they start to show a beneficial effect. Also acute medication has improved for migraine. However, if you are having at least four migraine attacks per month you may wish to discuss prophylactic medication with your GP.

It could take up to three months for the preventive effect of the drug to be felt. Therefore, if the drug did not relieve your migraine attack it does not mean that the drug itself did not work but that you need to give it some time. You must avoid overusing painkillers as this can make the headaches harder to treat.

It is important to note that some preventive drugs prescribed by your GP for your migraine may be licensed for other conditions such as high blood pressure, depression or epilepsy. This could mean that the information sheet is more relevant to those conditions. If you see information in the Patient Information Sheet which you don’t understand you should discuss this further with your GP.

All preventive treatments for migraine

(Tables taken from the British Association for the Study of Headache’s National Headache Management System for Adults 2019)

*Valproate Patient Safety Alert
In girls and women of childbearing potential, valproate should be initiated and supervised by a specialist and only prescribed when other medications have not been tolerated or have found to be ineffective. This is because of 30-40% risk of neurodevelopmental disability in unborn babies exposed to valproate (MHRA April 2017). Valproate should only be prescribed by following the MHRA guidance, including a signed contraceptive plan and signed consent form documenting discussion of the risks (see MHRA website).

Caution

Key

• POM – Prescription only medication
• OTC – over the counter medication
• ® – registered
• Enteric coated – tablets can be coated with a substance that enables them to pass through the stomach and into the intestine unchanged.
• IV – intravenous injection
• BNF – British National Formulary is the joint publication published by the British Medical Association and the Royal Pharmaceutical Society which is distributed to NHS doctors by the Department of Health.

For more information about a specific medicine, the electronic Medicines Compendium (eMC) website contains up to date, easily accessible information about medicines licensed for use in the UK.

Angiotensin II blockers

Action

Mode of action in migraine is unclear. They block the hormone angiotensin II. They are used in the treatment of hypertension.

Candesartan (generic name)

Candesartan is the only member of the AII antagonist group that has shown to have an effect in migraine.

Anti-convulsants

Action

Mode of action in migraine is unclear.  They may reduce the capacity of the nerves to transmit pain signals in the brain.

Special note

The Medicines and Healthcare products Regulatory Agency (MHRA) has a toolkit to ensure female patients are informed about the risks of taking valproate medicines during pregnancy – access ‘Valproate guide for patients‘ on the Gov.uk website >

Sodium valproate (generic name)

Topiramate

Gabapentin

Anti-serotonergic (Anti 5-HT) drugs

Action

Serotonin (5-HT) is a chemical occurring in the body, which is thought to play a key role in migraine.  These drugs block 5-HT₂ receptors to stop the effects of 5-HT.

Pizotifen (generic name)

Pizotifen also has anti-histamine properties and is related to the tricyclic antidepressants.

Methysergide

Methysergide, a semi synthetic ergot alkaloid, is currently not available – read more here >

Beta-blockers

Action

These drugs have several actions and are used to treat people with high blood pressure, but are also effective in treating migraine. They should be avoided by people with asthma.

• They reduce activity of the brain cells involved in migraine
• They can also reduce the dilation (widening) of arteries in the body.

Calcitonin Gene-Related Peptide pathway monoclonal antibodies

New treatment

These are the newest preventive medicines specifically developed and licenced for the treatment of migraine.

Most of the current preventive medicines used to treat migraine have been developed for other conditions. This is therefore an exciting development for migraine sufferers.

Read more about Calcitonin Gene-Related Peptide pathway monoclonal antibodies here.

Calcium channel blockers (calcium channel antagonists)

Action

Reduces calcium entry into neurons making them less ‘excitable’.  Blocks dopamine receptors in the brain.

Flunarizine (generic name)

Flunarizine is not widely available in the UK and is usually only prescribed by a specialist.

Non-steroidal anti-inflammatory drug (NSAID)

Action

NSAIDs reduce inflammation by inhibiting the production of certain chemicals in the body.

They should not be used as long-term preventives.

Naproxen (generic name)

Tricyclic antidepressants (TCAs)

Action

These drugs were previously used for depression, however, they are also effective at preventing migraine. They can be helpful in people with migraine who also have difficulty sleeping.

Tricyclic antidepressants are thought to:

• Block the re-uptake of 5-HT and norepinephrine
• May block 5-HT₂ receptors.

The products shown are most commonly used for the prevention of migraine.

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