Blood pressure drugs for the prevention of migraines

I see many patients who tell me that “I’ve tried every migraine drug” and seek me out to explore non-drug approaches, such as herbs, supplements, Botox, acupuncture and other. I always try to avoid using medications (and have written books on non-drug approaches), but some patients do best with a combination of medications and non-drug approaches. So, when someone tells me that they’ve tried “every drug”, I tell them that I’ve never seen such a person because there are so many drugs that we use to treat headaches. For example, they might’ve tried a blood pressure medication, but we have many different anti-hypertensive drugs and they work in different ways. One type of blood pressure medication may work when another does not. Also, if one drug caused side effects, another in the same or different category may not.
Here is a brief description of blood pressure medications that are used for the prophylactic treatment of headaches. The first medication approved by the FDA for the prevention of migraine headaches was propranolol (inderal) (methysergide or Sansert was approved earlier, but it is no longer available in the US). Propranolol was originally developed for the treatment of hypertension and then accidentally was found to help migraine headaches as well. A second beta blocker, timolol (Blocadren) was also tested, was found to work well and it also received FDA approval. Other beta blockers, such as atenolol (Tenormin), labetalol (Normodyne), and nebivolol (Bystolic) were also shown to be effective. Nebivolol tends to have fewer side effect, but it is not yet available in a generic form, so it can be relatively expensive. Propranolol is available in a slow release form (Inderal LA) which can be taken once a day, while regular propranolol goes in and out of the body quickly and needs to be taken two or three times a day. Atenolol and nebivolol produce effect that lasts all day, so they can be taken once a day. Atenolol is very inexpensive and I always remind patients to ask the pharmacist about the price without insurance because the insurance co-pay can be higher than the out-of-pocket cost of the drug. Most pharmacists will not volunteer this information.
Because beta blockers worked for migraines other blood pressure medications were also tested. Calcium channel blockers, such as verapamil (Calan), amlodipine (Norvasc), diltiazem (Cardizem), and other do not seem to be as effective as beta blockers. High doses of verapamil are very effective for the prevention of cluster headaches.
Another category of blood pressure medications, ACE (angiotensin converting enzyme) inhibitors, such as lisinopril (Zestril, Prinivil), enalapril (Vasotec) and other do help probably as well as beta blockers. These medications sometimes cause cough or other side effects and can be substituted by similar drugs in the category of ACE receptor blockers (ARBs). ARBs do not cause cough and may have fewer other side effects. Drugs in this group that were studied for the prevention of migraine headaches include olmesartan (Benicar), losartan (Cozaar), and candesartan (Atacand).