What can I do to prevent migraines?

DEAR DOCTOR K:

I suffer from excruciating migraine headaches. What can I do to prevent them?

DEAR READER:

Migraines are severe, throbbing, often debilitating headaches. They can be accompanied by nausea or vomiting. It’s no wonder that anyone who suffers from migraines would do anything to avoid them.

Migraines can be triggered by certain activities, foods, smells or emotions. Common migraine triggers include:

  • Caffeine (either too much or cutting back on regular use).
  • Certain foods and beverages. These include foods and drinks that contain tyramine (aged cheeses and meats, fermented beverages), sulfites (preserved foods, wines) and monosodium glutamate (MSG), a common flavor enhancer.
  • Stress.
  • The opposite: relaxing after a stressful day or week. Many people get their migraines most often on the weekends.
  • Hormone levels (menstrual cycles, medications such as birth control pills that contain hormones).
  • Lack of sleep.
  • Changes in weather or altitude.
  • Overuse of pain-relieving medications.

If you can identify a trigger, try to avoid it. Some people also find that alternative treatments help. These include biofeedback, yoga, acupuncture and massage.

But some people get frequent and severe migraines no matter how well they avoid triggers. If your migraine attacks are severe, do not respond to treatment or occur more than four times a month, look into the following preventive treatments:

  • TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS). The FDA approved the first TENS device for migraine prevention in 2014. Placed on the forehead, it applies an electrical current that stimulates nerves in the brain that process pain.
  • PREVENTIVE MEDICATIONS. Several types of medications are used to reduce the frequency of migraine headaches. These include beta blockers, tricyclic antidepressants, calcium-channel blockers and anticonvulsants.

There are some studies that suggest taking low-dose aspirin every day may reduce the frequency of migraines. I suffered from migraines in my 30s, and daily low-dose aspirin has eliminated them nearly completely.

Below, I’ve put a table listing examples of each type of drug that has been well studied. These medications must be taken every day to be effective.

  • BOTOX INJECTIONS. If you experience more than 14 migraines per month, botulinum toxin (Botox) injections may help reduce their number.
  • NEW APPROACHES. One of the most anticipated new treatments (still in clinical trials) involves biological compounds that target CGRP, a chemical in the body that inflames nerve endings. It is also a strong blood vessel dilator. As blood vessels widen in response to CGRP, they press on nerves that trigger pain. It’s a vicious cycle: When activated, the nerves release more CGRP into the bloodstream. Blood levels of CGRP rise during migraine attacks and decline as headaches subside. The new treatments are designed to prevent migraines by deactivating CGRP for stretches of time.

As someone who has experienced migraines, I hope one or more of these approaches will offer relief from your pain.

Medications that help prevent migraine headaches
Class Generic name
(brand name)
Side effects Cautions
Beta blockers atenolol (Tenormin) bisoprolol (Zebeta) metoprolol (Lopressor) nadolol (Corgard) propranolol (Inderal) timolol (Blocadren) Fatigue, dizziness, depression, cold hands and feet, exercise intolerance, fatigue, insomnia, and impotence People with heart failure, asthma, or other lung conditions should be closely monitored by a physician if they take these drugs.People taking thyroid medication should not take propranolol.
Tricyclic medications amitriptyline (Elavil, Endep) doxepin (Adapin, Sinequan) imipramine (Tofranil) nortriptyline (Aventyl, Pamelor) Drowsiness, dry mouth, blurred vision, weight gain, constipation, urinary retention Do not take these drugs if you have glaucoma, heart disease, or an enlarged prostate, or if you are taking a monoamine oxidase inhibitor (MAOI) such as isocarboxazid (Marplan), phenelzine (Nardil), or tranylcypromine (Parnate).
Calcium-channel blockers verapamil (Calan, Isoptin, Verelan) Fatigue, dizziness, constipation, swollen ankles, and fluid retention People with heart failure or problems with the electrical pathways in the heart should not take these drugs.
Anticonvulsants divalproex (Depakote) Nausea, diarrhea, weakness, tremor, and weight gain People taking this medication need regular blood tests to monitor their liver function.Don’t take this drug if you have any liver problems, including elevated liver enzyme levels.
gabapentin (Neurontin) Drowsiness, fatigue Although this drug is not specifically approved for migraine headache treatment, doctors sometimes prescribe it to prevent migraine.
topiramate (Topamax) Drowsiness, loss of memory or thinking skills, weight loss, word-finding problems, tingling in hands and feet Don’t take this drug if you have a history of kidney stones.