Forebyggende behandlinger - hvad skal man vælge?

Side effects
Betabockers
Candesartan
Medicine against epilepsy  
Other types of medicine  
Preventive treatment is short lasting  
Preventive medicine tfor chilren with migraine

Doctors usually offer preventive treatment if you 1) have 2 to 6 migraine attacks per month, 2) if the acute treatment of the migraines is not effective, or 3) if the acute treatment leads to unacceptable side effects.

If you have more than six migraine attacks per month it should be assessed whether a non-medical treatment (including stress management, minimization of triggers and physical therapy) may reduce the migraines.

Moreover, it is extremely important to clarify whether the migraines are caused by overuse of acute medications. Medication-induced headaches can be triggered by all kinds of specific migraine medication, sumatriptan, zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan and ergotamine if you take the medication more than 10 days per month during a few months.

OTC drugs as aspirin and paracetamol for more than 15 days per month can also provide medication-induced headaches. If you have a medication-overuse problem,  preventive treatment does not have an effect, and your medication consumption should be revised before starting on preventative treatment.

Normally one can expect that preventive treatment of migraine provides 50% reduction in seizures in 50% of patients. But the results of the preventive treatment varies from patient to patient. Some respond well to one treatment and others on another. The doctor and the patient must patiently try them. It typically takes 3 months before we can see whether a particular treatment has an effect. Top

Side effects

Because different types of preventive medicine is roughly equal in terms of efficacy, the choice of first-line medications is often determined by what side effects the medication has. Here it is important to adapt this to the individual with migraine. If, for example, you have asthma, certain types of medications are not appropriate, and if you are overweight, avoid drugs that induces weight gain.

It's fortunately that only a minority of patients  get these side effects (see table below). It is important to keep a headache calendar while taking preventive medicine, so it can be shown whether and to what extent the medication works. Most forms of preventive medicine has been developed to treat other diseases, and we have only later found out that they are also works for migraine.

Clinical efficacy, scientific evidence of efficacy, potential side effects and examples of adverse events graded on a scale from + to + + + + for drugs used in the preventive treatment of migraine.

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Anti-hypertension (beta blockers)

Beta-blockers such as propranolol and metoprolol have proven efficacy as a preventive medication for migraine. They are sold under the names Inderal, Propal, Propranolol, Metoprolol, Dura-Zok and Selo-Zok. There is considerable difference in how much each patient should take of  these medications, so you start with relatively small doses and then gradually increase the doses. The highest daily dose is usually 160 mg for propranolol and 200 mg of metoprolol. Side effects include fatigue, cold fingers and toes, vivid dreams and depression. Candesartan (Atacand) is another type of blood pressure medications. There is less scientific basis for the effect than for beta-blockers but then also fewer side effects.

Migrænikerforbundet finds that it is important that physicians offer preventive medication for migraine patients who have many migraine days. But it is sad that it is so difficult to find the 'right' way, and that some simply can not be helped with preventative medical treatment. Top

How does betabokkere work?

Beta blockers work by blocking (reduce) the effect of norepinephrine in the arteries and heart muscles. Norepinephrine is a neurotransmitter that sends a message between nerve and muscle or between two nerves. When this message is blocked, blood vessels are dilated and the heart beats slower and with less power. This produces a decrease in blood pressure and have proven to reduce migraine in some severely affected migraineurs. Top

Beta blockers are not for pregnant and nursing mothers

Pregnant women should not take beta blockers as they may cause the fetus problems with blood sugar. But it can be a balancing of risk to the mother if she has high blood pressure. Are you pregnant or planning to become so and take beta blockers, you should have a good talk with your doctor. Beta-blockers are transported into the milk if you are breastfeeding. Top

Beta-blockers and other diseases and medicines

If your doctor offers you beta blockers, it is important that you tell whether you have allergies, asthma, eczema or bronchitis because beta blockers narrows the airways, if you have unusually slow heartbeat, diabetes (beta-blockers can cause high blood sugar and increased circulatory problems), kidney or liver disease (because beta blockers slows the excretion of waste substances from the body) if you are suffering from depression (they can be increased by beta blockers), if you have myasthenia gravis, psoriasis, or overactive thyroid (beta blockers may mask an increased heart rate).

Finally, it is not a good idea to mix beta blockers with cocaine or calcium channel blockers; have you taken monoamine oxidase inhibitors (for depression) you  should have a break of at least 2 weeks before you start on beta blockers - otherwise there is risk of severe hypertension.

Beta blockers are not good when mixed with pain relievers (over the counter medicine) and other blood pressure lowering drugs (including herbal medicines). It is also not good to mix beta blockers with any medicines (including herbal medicines etc.) affecting the heart's rhythm, and some medicines for colds and appetite weakness can cause a dramatic increase in blood pressure when mixed with beta blockers.

So if you are considering beta blockers, you must first have a good talk with your doctor! Top

Candesartan (an angiotensin II inhibitor)

Candesartan (sold under the name Atacand ) is an angiotensin II inhibitor andis effective against high blood pressure. The substance causes blood vessel walls to relax, thereby reducing blood pressure. Remember to tell your doctor if you have allergies or kidney problems if you are offered Candesartan. One should not take this drug during pregnancy, especially in 2 and 3 trimesters. Top

Anti-epileptics

Gabapentin (Pfizer) can no longer be recommended as a preventative for migraine, as a review of Pfizer's internal documents compared with the published results have shown that the published results are 'improved' compared to the original data. Read more here (the original press release from the Associated Press, November 11, 2009, in English).

Topiramate (Topamax) has proven efficacy. The dose is increased slowly to avoid side effects, typically 50 mg twice daily. Most common side effects are tingling in fingers and toes and weight loss and less often drowsiness and difficulty concentrating.

Topiramate may reduce the effect of contraceptive pills with estrogen.

Valproate (Delepsine, Deprakine, Orfiril) also has documented efficacy in migraine treatment. There is usually 600-1200 mg in one dose per day. In the beginning your doctor should take blodsamplesfor checking. Possible side effects are tremors in hands, weight gain and loss of hair.

Valporat should not be used during the first 3 months of pregnancy, as there can be deformities in the child. You should not breastfeed while taking Valporat.

Valporat (in larger quantities than the dose used to treat migraine) may cause damage to liver, kidneys and pancreas. The substance also changes the effect of a variety of other types of medication, so it's important to tell your doctor about the use of such medicnes as aspirin, antidepressants and antabuse. Top

Other types of medication

Flunarizine (Sibelium) is a calcium channel blocker and has proven efficacy in migraine.When the transport of calcium is blocked in the cells of blood vessel walls and in the heart, it relaxes those muscles a bit, and blood pressure drops. One begins usually with 5 mg daily and could increase to 10 mg. The side effects are drowsiness, weight gain and depression.

Remember to tell your doctor about other medicines you use, because there are many types that do not fit together with flunarizine, for example diuretics.

Tolfenamic acid (Migea, Clotam Retard) is a rheumatic agent (NSAID) that has a documented effect. The dose is 300 mg daily. Side effects include abdominal pain, nausea, diarrhea and the risk of ulcers.

Pizotifen (Sandomigrin) is an antihistamine and has some proven efficacy in migraine. The usual dose is 1.5 mg daily. The side effects are drowsiness and weight gain. The remedy should not be taken with an MAO inhibitor. If you have glaucoma youshould not use this medicine.

Peer Tfelt-Hansen and Lars Bendtsen, 2006. What types of preventive medicine offers doctors of migraine? Migrænenyt 2006-1, page 8-11.

You can find the information slip for these medicines on Medicines Agency's website. Search under the trade name for the product. Top

Preventive treatment often lasts only a short time

A study from Holland showed that migraineurs who take preventive medication usually stops medication again after a short time.  About half of those who started on preventive therapy stopped again within 3 months.

The migraineurs who took valporat continued for longer than those who took beta-blockers, clonidine or flunarizine. Only about 20% of patients continued with the latter preparations after 1 year.

The study's authors do note that they do not know why patients stopped taking the medicine. This may be because they thought it was no longer needed or because there were side effects that were so severe that they  would rather do without the medicine.

H. Rahimtoola, H. Buurma, CC Tijs, HG Leufkens and ACG Egberts, 2003. Migraine prophylactic medication usage patterns in the Netherlands. Cephalalgia 23, 293-301.Top

Preventive treatment for children with migraine

Yes, it sounds drastic, but there are children who have so much migraine that there may be reasons to consider a preventive treatment.

Around the world there have been some trials of preventive treatment of children with a variety of medications that are also used for adults.

Amitriptyline (Saroten) is an anti-depressant, which gave 80% of children (192 children) significantly reduced the frequency of attacks, but each attack was just as long as before treatment.

Propranolol (Inderal, Propal) is an antidepressant beta-blocker, and a number of trials in children have given varying results from total cessation of migraine in 71% of children to increased migraine.

Cyproheptadine (Periactin) is an antihistamine and it gave 83%  of a group of children a halving of the number of attacks, but seemed also sedative and gave increased appetite.

Clonidine (Catapresan) is an antiepileptic that have shown a good effect in one study and no effect in another.

Topiramate (Epitomax, Topamax) is an antiepileptic agents that reduced the number of migraines by 70% in a group of children. They told about side effects like drowsiness, lack of appetite and weight loss.

Naproxen sodium (Bonyl, Naprosyn) is an NSAID, and were tried by 10 young and 6 of them had less than half as many attacks as before treatment.

So if a child has a good many migraine attacks it might be worth talking with your doctor whether it is advisable to seek preventive care.

None of these studies included a large number of children, so the results should be seen as indicative.

DW Lewis, S. Diamond, D. Scott and V. Jones, 2004. Prophylactic treatment of Pediatrics migraine. Headache 44, 230-237.

Updated 12 November 2009. Top