Blood pressure drugs prevent migraines but may cause depression

Beta blockers, such as propranolol (Inderal) and timolol (Blocadren) are the oldest drugs for the prevention of migraine headaches. They’ve been used for this indication for the past 50 years. Calcium channel blockers are not as effective and never received FDA approval, but are also used treat migraine headaches. Verapamil is more effective for the prevention of cluster headaches, but is not approved for this indication either. A third category of blood pressure drugs effective for the prevention of migraines are ACE receptor blockers (ARBs) such as candesartan (Atacand) and olmesartan (Benicar) and ACE inhibitors such as losartan (Cozaar).

Main side effects of these drugs tend to be related to lowering of blood pressure and include fatigue and dizziness. This is a major limitation of blood pressure medications when used in migraine sufferers because they tend to be young women with low blood pressure to begin with. Verapamil is also known to cause constipation.

Beta blockers and to a lesser extent calcium channel blockers, have long been reported to cause depression. A new study just published
in the journal Hypertension explored the association between blood pressure drugs and admission to to the hospital for mood disorders (depression and bipolar). The researchers examined a large hospital database of 525,046 patients with follow-up for 5 years. Patients on ACE inhibitors or ARBs had the lowest risk for mood disorder admissions, and compared with this group, those on beta blockers and calcium channel blockers showed higher risk, whereas those on no blood pressure medications and those on diuretics showed no significant difference. The authors concluded that calcium channel blockers and beta blockers may be associated with increased risk of admission for mood disorders, while ACE inhibitors and ARBs blockers may be associated with a decreased risk of mood disorders.

Migraine sufferers are at 2-3 higher risk of mood disorders even if they are not on blood pressure medications and we often see depression and anxiety in many of our patients. This study makes a strong argument for the use of ACE inhibitors and ARBs ahead of other blood pressure medications. Another advantage of these drugs is that they do not slow down the heart rate, which is the case with beta blockers. Slowing of the heart rate often interferes with the ability to exercise and exercise is probably the most effective preventive treatment for migraine headaches.

I should also mention that epilepsy drugs such as topiramate (Topamax) can also cause depression, even with suicidal thoughts. Besides blood pressure and epilepsy drugs, antidepressants is another category of drugs used for the prevention of migraines, but even these medications can sometimes cause or worsen depression. All drugs have other side effects as well and this is why we always advise starting with sleep hygiene, healthy diet, aerobic exercise, meditation, magnesium, and other supplements.