For many people with frequent migraines, relying solely on acute treatments (taken to stop an attack once it starts) is not enough. Taking acute pain relievers too often can lead to medication overuse headaches, which paradoxically increases headache frequency. This makes daily preventive medication a crucial strategy for those who experience migraines multiple times per month.
Newer Oral Medications (Gepants)
An innovative class of oral medications, known as gepants, is specifically designed to prevent migraines by targeting calcitonin gene-related peptide (CGRP), a molecule involved in migraine pain.
Atogepant (Qulipta)
Atogepant (Qulipta) is a once-daily oral tablet approved for the preventive treatment of both episodic and chronic migraine in adults. It works by blocking the CGRP receptor, thereby preventing CGRP from causing the inflammation and vasodilation associated with migraine. Common side effects include nausea, constipation, and fatigue.
Rimegepant (Nurtec ODT)
Rimegepant (Nurtec ODT) is unique as it can be used for both the acute treatment of a migraine attack and for prevention when taken every other day. This orally disintegrating tablet also works by blocking the CGRP receptor. Side effects can include nausea, dry mouth, and sleepiness.
Older Preventive Medications
Before the development of CGRP inhibitors, several other classes of medication originally designed for different conditions were found to be effective for migraine prevention.
Anticonvulsant Medications
- Topiramate (Topamax): Approved for migraine prevention, Topiramate is an anti-seizure drug that works by calming overactive nerves in the brain. It is typically started at a low dose and gradually increased. Side effects can include cognitive issues (sometimes called "brain fog"), weight loss, and tingling sensations. It's not recommended for people who are pregnant or trying to become pregnant.
- Divalproex Sodium (Depakote): This anti-seizure drug is another option for migraine prevention. Like Topiramate, it requires careful monitoring and is not recommended during pregnancy. Side effects can include weight gain, hair loss, and drowsiness.
Beta-Blockers
Beta-blockers, primarily used for high blood pressure and heart conditions, are a cornerstone of traditional migraine prevention. They work by slowing the heart rate and relaxing blood vessels, though the exact mechanism for migraine prevention isn't fully understood.
- Propranolol (Inderal): One of the most studied and effective beta-blockers for migraine prevention.
- Metoprolol (Lopressor, Toprol-XL): Another commonly used beta-blocker for migraine prophylaxis.
Antidepressants
Certain antidepressants, particularly older tricyclic antidepressants, have been shown to help prevent migraines. Their efficacy is thought to be related to their effects on neurotransmitters like serotonin.
- Amitriptyline (Elavil): A tricyclic antidepressant with a long history of use for migraine prevention.
- Venlafaxine (Effexor XR): An SNRI antidepressant that can be an alternative for those who don't tolerate tricyclics well.
Other Preventive Therapies
For some patients, especially those with chronic migraine (15 or more headache days per month), other forms of preventive treatment may be more suitable.
- CGRP Monoclonal Antibodies: These injectable or infused medications block CGRP or its receptor and are administered less frequently than daily oral medications.
- Erenumab (Aimovig): Monthly subcutaneous injection.
- Fremanezumab (Ajovy): Monthly or quarterly subcutaneous injection.
- Galcanezumab (Emgality): Monthly subcutaneous injection.
- Eptinezumab (Vyepti): Quarterly intravenous infusion.
- Botox Injections: OnabotulinumtoxinA (Botox) is approved for chronic migraine and involves injections into specific head and neck muscles every 12 weeks.
Comparison of Daily Migraine Medications
| Feature | Atogepant (Qulipta) | Topiramate (Topamax) | Propranolol (Inderal) |
|---|---|---|---|
| Drug Class | CGRP Inhibitor (gepant) | Anticonvulsant | Beta-Blocker |
| Typical Dosage | Once daily oral tablet | Once or twice daily oral tablet | Multiple daily oral doses |
| Mechanism | Blocks CGRP receptor, preventing pain signals | Calms overactive nerves, reduces pain signals | Slows heart rate, relaxes blood vessels |
| Common Side Effects | Nausea, constipation, fatigue | Tingling, fatigue, cognitive issues, weight loss | Fatigue, dizziness, low blood pressure, depression |
| Heart/Vascular Risk | Generally considered safe for cardiovascular patients | Low risk | Avoid in uncontrolled hypertension or heart disease |
| Pregnancy Risk | Unknown, consult doctor | Not recommended, significant risk | Consult doctor |
Choosing the Right Medication
Choosing the best daily medication involves a detailed discussion with a healthcare provider. Factors to consider include:
- Frequency and severity of migraines: Daily medication is typically recommended for those with frequent attacks (e.g., four or more per month) or highly disabling ones.
- Comorbidities: Conditions like high blood pressure, heart disease, or depression can influence the choice of medication. For example, beta-blockers might benefit someone with both high blood pressure and migraines.
- Side effect profile: Each medication has a different set of potential side effects. Some older drugs may have more significant systemic side effects, while newer CGRP inhibitors are often better tolerated.
- Patient preference and adherence: The ease of administration (oral tablet vs. injection) and dosage frequency can affect a patient's ability to consistently take their medication. Newer options like Atogepant offer a simple once-daily oral regimen.
Conclusion
For those burdened by frequent or severe migraines, daily preventive medication can be a life-changing intervention. The landscape of options has expanded significantly with the advent of targeted therapies like CGRP inhibitors (e.g., Atogepant, Nurtec ODT), which offer a new path for many patients. However, traditional treatments such as beta-blockers, anti-seizure drugs, and antidepressants remain valid options, especially when addressing co-existing conditions. Given the complexity of migraine and individual health needs, an informed conversation with a healthcare professional is essential to determine the most effective and safest daily regimen for long-term management.
