Updated Answer to "Best RX for Migraine Prevention"
In the Migraines and Headaches Community, tia1977 posted a question asking what the best prescription for migraine prevention was. I think that this is a very interesting question that we probably all want to know the answer to and I still think that there is no simple answer since we are all so individual and unique... BUT!
I remembered an article I read called "Evidence-Based Guidelines for Migraine Headache in the Primary Care". I am not exactly sure, but I do believe it was written over 10 years ago... so a lot of the information is going to be quite out-dated.
Still, I thought the article was relevant to the question so I thought I would mention it. Basically the article looked at multiple articles that were published prior to it, and complied all the data to analyze and compare the data and then put the data into a comparison chart so that prescribing preventative treatments for migraines would be easier for physicians. They looked at how well the medications did in the scientific, double-blind, placebo controlled trials... then they also looked at how well the medication did in clinical studies as well (so, more like, "real life" sort of situations)... and they also looked at the side-effects and took those into consideration too, because what good is a medication if it takes away all your migraines but also kills you, right? Then they put all that information into a chart and graded all the medications.
SO! What the study revealed... and this is why your doctors usually prescribe the medications they do in the orders that they usually do (of course there are always exceptions, but, for the most part, the majority of doctors will prescribe the preventatives in these orders the majority of the time, or at least, they did 10 years ago) ...
In the category of ANTICONVULSANTS:
- Valproic Acid came in first place, it was basically the "best" at the time in the category of anticonvulsants (often prescribed as Sodium valproate or Divalproex sodium). It got a 3/3 for scientific effect in that "The effect is statistically significant and far exceeds the minimally clinically significant benefit." It got 3/3 for clinical effectiveness in that it was "Very effective: most people get clinically significant improvement." side effects were occasional to frequent. An interesting note here, the first anticonvulsant that I was prescribed was Valproic Acid.
- In second place for anticonvulsants, they listed Gabapentin. 2/3 for scientific effect in that "The effect of the medication is statistically significant and exceeds the minimally clinically significant benefit." 2/3 for clinical effectiveness in that it is "Effective: some people get clinically significant improvement". side effects were occasional to frequent.
- The study actually gave Topamax quite a low grade but it was because no scientific trials had been done at the time to prove that it was a migraine preventative... trials have been done now to prove that it works as a migraine preventative but back then I think it was only being used off-label, but they did note that Topamax showed "some people [got] clinically significant improvement," which was a 2/3 score for clinical effect. Like most of us are familiar with here (although hopefully not most of us personally!) they note the side-effects regarding kidney stones. They also note the side effect regarding weight loss which is something that most of us are personally familiar with.
In the category of ANTIDEPRESSANTS:
- Amitriptyline won. scientific evidence is trustworthy and strong. 3/3 for scientific effect. 3/3 for clinical effect. Lots of side-effects though.
- Nortriptyline lost basically in every way except that in clinical studies it worked as well as the Amitriptyline. Just in scientific trials it didn't work as well as the Amitriptyline, it didn't even work better than the placebo. But, less side-effects than Amitriptyline.
- All other antidepressants lost.
In the category of BETA BLOCKERS:
- Propranolol and Timolol tied. Best scientific evidence in terms of reliability and trustworthiness out of all the beta blockers. 2/3 in the scientific trials for both. 3/3 in the clinical trials for both. infrequent side-effects for both.
- The rest of the beta blockers they list all got a 2nd place sort of rating, they beta blockers are: Nadolol, Metoprolol, Atenolol. All had infrequent side-effects. Metoprolol and Atenolol faired better in the scientific trials with a 2/3 rating, but Metoprolol and Nadolol faired better clinically with a 3/3 rating.
In the category of CALCIUM CHANNEL BLOCKERS:
- At the time, the side-effects of the calcium channel blockers were all quite frequent and could be severe, so calcium channel blockers weren't usually recommended as a first line treatment. So, there was no "first place winner" for the Calcium Channel Blockers. Diltiazem appeared to be the clear loser though. I guess the choice of which to take would have been between Verapamil and Nimodipine. But... it's been 10 years, things might have changed, as they have for the anticonvulsants.
In the category of OTHER:
- Vitamin B2 seems to be the winner. 2/3 for how strong the evidence is. 3/3 for how well it works in scientific trials. 2/3 for how wells it works in clinical setting. No side-effects.
- For menstural migraines, Estradiol gel (like what people use for menopause). I tried this before. 2/3 for how strong the evidence is. 2/3 for how well it works in scientific trials. 2/3 for how well it works in clinical setting. infrequent side-effects.
- Amitriptyline - 30mg to 150mg
- Valproic Acid - 500mg to 1500mg
- Lisuride (didn't mention it before because it's still not available in America or Canada)
- Propranolol - 80mg - 240mg
- Timolol - 20mg - 30mg
Second place winners (as of 10 years ago):
Atenolol - 100mg
Feverfew - 50mg- 82mg
Gabapentin - 900-2400 mg
Fluoxetine - 20 mg every other day to 40 mg a day
Guanfacine - 1mg
Magnesium - 400mg - 600mg
Metoprolol - 200mg
Nadolol - 80mg - 240mg
Nimodipine - 120mg
Verapamil - 240mg
Vitamin B2 - 400mg
A few more notes...
This is an old study. They mention using NSAIDS as preventative treatment, but SO much work has been done since that has shown very clearly how daily NSAIDS cause chronic migraine headaches and do not prevent migraine headaches. Also, they mention Fluoxetine (an SSRI which is rarely used today for migraine prevention) as a treatment on par with current first line migraine prophylactic. So, with this in mind, take this study lightly... it is an interesting read and still has relevant and useful information in it... but if your neurologist says different (always listen to the advice of your neurologist) or you read multiple new peer-reviewed journal articles that differ with this information then go with the NEW information because this is OLD and dated information.
But... still... just for fun I thought I'd offer up a scientific, if somewhat dated, answer to the question of "what's the best RX for migraine prevention?"
My personal answer is still the same though... we are all very unique and although first line treatments should always be tried, well, first... they might not end up being the best treatment after all. Plus, there are three whole separate classes of first line preventatives... so even if we did go by the one with the highest probability of effectiveness in each category, that still leaves at least three treatments to try! It's really, unfortunately, somewhat of a guessing game that eventually turns into a precise art of fine tuning based on that individual and specific situation.
Thank you SO MUCH for the info! It's a wonderful and easily accessable resource! My eyes (and brain;ha) get so tired trying to look up so much of the info I want to know on the internet. Unfortunately, I know it comes w/ the huge price of how you have sufferred so long w/ this crud. However, you are an xtremely valuable resource for information in how we can either help ourselves better, or raise the right questions to our neurologists so that they can help us better (: Thanks again...
This is helpful--to have such information in a more concise format. Hmm, there is good reason why the stuff I've tried so far does--nothing. Seems some of the stuff I've tried has been at really low doses by comparison. I know it's going to take a while to figure out the right combo for me.
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