The Top 10 Prophylactic Treatments for Migraines
In a recent post, I listed the top 10 acute treatments for migraine attacks that are mentioned in my book, The End of Migraines: 150 Ways to Stop Your Pain. Here is a list of the top 10 preventive drug therapies for migraines. In the next post, I will list the top 10 non-drug therapies.
The order of choices can vary depending on co-morbidities, potential side effects, cost, and other factors. For example, patients with coexistent anxiety and/or depression would have duloxetine and nortriptyline move higher on this list. Patients with rapid heartbeat, anxiety, or PTSD could start with nebivolol. Those with high blood pressure, could start with candesartan or nebivolol, and so on.
- OnabotulinumtoxinA (Botox)
- Atogepant (Qulipta)
- Rimegepant (Nurtec)
- Galcanezumab (Emgality)
- Nebivolol (Bystolic)
- Propranolol (Inderal)
- Candesartan (Atacand)
- Duloxetine (Cymbalta)
- Nortriptyline (Pamelor)
- Fremanezumab (Ajovy)
It’s typical for people to start feeling relief from their migraines a few weeks to a month or two after Botox treatment. Some patients may come back for a follow-up appointment three months after treatment claiming that Botox did not help, but when their disability score on the MIDAS scale is reviewed, it shows a significant improvement. This is often because the improvement for many people is very gradual. In some cases, people may only notice an improvement after their second Botox treatment, and migraines may continue to improve with each subsequent treatment. Studies have shown that continued improvement can occur for up to two years. Some fortunate patients may experience relief for much longer than three months, possibly due to a sustained disruption of the migraine process in the brain, rather than an ongoing effect of Botox. However, for most people, the effects of Botox wear off after three months.
Thanks – this is such a helpful list. Regarding botox, is it possible to only see benefits after two months? And then to have three migraine-free months, following those first two? That seemed to be the case with me. It was my first botox treatment, and the migraines have since returned (5 months after the injections), but based on what I read, it seemed unlikely that it would take that long for botox to work. What do you think?
Some background: My chronic migraines started about 4 years ago. They only become severe and chronic (~15 days/month) after giving birth and ending breastfeeding. Before that, I had them maybe once a month, easily treated with sumatriptan. And when I was pregnant, I actually had zero migraines.