An ounce of prevention

Migraine Prophylaxis

A few weeks ago we talked about types of headaches and how to diagnose.  Another headache issue that comes up often in clinic is prevention.

You should think about prophylactic medicines in your patients who have more than 3-4 severe headaches a month, headaches lasting more than 12 hours, or really in anyone who feels like they have enough headaches that it is worth it to them to take a daily (sometimes more than daily) medicine to prevent headaches.  It is also helpful in those who you are concerned about rebound headaches, to help them use less of their abortive medicine.

Typical results are 50-75% of patients get 50% reduction in headaches- either intensity or frequency.  Can take a month to see results, and up to 3 months to get peak results. You have to titrate medicines to good doses, and leave the patients there for a while to give a good trial of therapy. I’ve listed some  medicines and typical doses below.

Beta Blockers

Fairly good data for the more selective: metoprolol, propranolol, and timolol.
Less data for atenolol.
Often limited by blood pressure and heart rate, but titrate to reasonable doses (heart rate 60-70s)

Calcium Channel Blockers

Verapamil (120-240mg divided daily) and Nifedipine have some, albeit weak, data.

ACE Inhibitors

One trial for Lisinopril and one for Candesartan showed benefit. Leads me to think that perhaps any blood pressure lowering may be helpful for migraines.


Tricyclics: amitriptyline most commonly, and most studied, but other should work as well. 20-50mg at bedtime
Venlafaxine 75-150mg daily.  More data with this than with traditional SSRIs.


Valproic Acid 500-1500mg daily. Side effects of weight gain, somnolence, hair loss Can’t use in women of childbearing age
Topiramate 25-100mg daily. Side effects weight loss, confusion/concentration issues/memory loss

picture is totally unrelated, but I just thought it was funny. Cigarettes are not recommended for migraine prophylaxis


Just came across this article JGIM (subscription or UAB access needed).  The authors systematically reviewed drug trials for migraine prophylaxis.  Turns out, everything studied (those things listed above) work fairly equally well.  All reduce headache frequency by about 50%. Antiepileptics and antidepressants had more side effects, and were more likely to be stopped.
  • take home point: think about beta blockers and ACE-I/ARBs for migraine prophylaxis, as they have the best risk/benefit ratio.

A pain in the head

Not sure why I always post about pain on Fridays, but here I go again. We’ve had some discussions about headaches in Red Clinic lately (and I don’t mean the VA formulary), and I thought it would be useful to review some diagnostic strategies.


Remember the mnemonic:  POUND Pulsatile One day Unilateral Nausea Daily activity (Interferes with daily activity) These are intense, debilitating headaches, often with  nausea and photo/phonophobia. Patients will “take to the bed” to get over them. May have an aura: visual or sensory disturbances that are fully reversible.

Tension Headache

Milder in intensity, bilateral, throbbing in quality. May have muscle tenderness over the scalp or neck. Patients usually can stay at work, continue activities with these headaches.

Cluster Headaches

Rare Patients  have episodes of daily headache, intense, usually unilateral and associated with autonomic symptoms.  They will have symptom free periods between “clusters” for months or even years.

Medication Rebound Headache

Common Daily headache associated with regular use of almost any medicine for headache treatment.  Most common with opiates, butabital containing meds (Midrin), or caffeine containing meds (fioricet or excedrin). Intermediate risk of triptans. Lowest risk with NSAIDs.