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For tension-type headache attacks, the typical nonprescription pain reliever will usually put an end to the mild pain. However, for the millions of people with migraine, nonprescription pain relievers often aren’t enough.
Not only do these medicines fail to stop the pain, nausea, light-sensitivity and other migraine symptoms, but they also can lead to rebound headaches if taken more than 2 to 3 times per week.
That’s why healthcare professionals recommend preventive migraine medications for people who experience more than four migraine attacks on more than four days per month. These prescription drugs can reduce migraine frequency and severity, minimizing the need for pain relievers.
“For people who experience frequent migraine attacks, preventive medicines can be life-changing,” says Amaal J. Starling, M.D., anassociate professor of the Department of Neurology with Mayo Clinic. “They do more than reduce the frequency and severity of their migraine attacks. They help people get their lives back.”
First-generation migraine treatments
Many older migraine medications were originally developed to treat other conditions. After these medicines gained Food and Drug Administration (FDA) approval for other conditions, however, healthcare professionals discovered that they also worked effectively as treatments for migraine.
These oral migraine medications include:
- Blood pressure and heart medications such as metoprolol (Lopressor) or propranolol.
- Antidepressantslike amitriptyline and venlafaxine (Effexor XR, Pristiq).
- Seizure medicines like valproate and topiramate (Topamax).
The Pros
About half of people who take these first-generation drugs experience a 50% reduction in the frequency of their headaches. Because these medicines have been around for many years, they tend to cost much less than newer migraine therapies. They also are more likely to be covered by insurance as an initial therapy.
Another plus: First-generation medicines can often treat more than one health problem.
“Often, when people talk about prescription medicines, they focus on the downsides,” says Dr. Starling. “However, some first-line medicines offer attractive side benefits.”
For example, when taken in the evening, the antidepressant amitriptyline can help people with insomnia fall asleep more easily. Similarly, in addition to reducing the frequency and severity of migraine attacks, the anti-seizure medicine topiramate has been shown to help improve blood sugar control, reduce calorie intake and binge eating, and help people lose weight. Finally, the antidepressant venlafaxine may help to alleviate anxiety in addition to migraine.
The Cons
Some first-generation oral migraine medicines lead to unwelcome side effects, especially in higher doses. For example, some people report that the antidepressant amitriptyline makes them feel overly fatigued during the day. Others say that the anti-seizure medicine topiramate leads to dizziness, anxiety, or pins and needles sensations, among other side effects.
Another downside: These medicines can be slow-acting, taking 8 to12 weeks to reduce migraine severity and frequency.
Second-generation migraine treatments
In the past several years, the FDA has approved many drugs developed specifically to treat migraine.
These medicines target calcitonin gene-related peptide (CGRP), a protein that can cause inflammation and pain associated with migraine. They are available as tablets, injections or infusions and are taken daily, monthly or once every three months.
| Drug name | Delivery Method | How Often |
| Erenumab (Aimovig) | Injection | Monthly |
| Fremanezumab (Ajovy) | Injection | Monthly or quarterly |
| Galcanezumab (Emgality) | Injection | Monthly |
| Eptinezumab (Vyepti) | Infusion | Quarterly |
| Rimegepant (Nurtec) | Tablet that dissolves in the mouth | Every other day |
| Atogepant (Qulipta) | Tablet | Daily |
The Pros
Newer migraine medicines have been shown to work as effectively as first-generation treatments.[6] They also tend to be better tolerated.
However, unlike first-generation treatments, which must be taken daily, many of the newer medicines only need to be administered monthly or quarterly. Rimegepant (Nurtec) and Atogepant (Qulipta) are exceptions.
The Cons
Second-generation treatments cost much more than first-generation options. As a result, your insurance company may not cover them initially, requiring you to try first-generation oral therapies first. This is known as “step therapy.”
For many insurers to authorize a second-generation treatment, two or more first-generation medications must be ineffective, poorly tolerated or not an option due to your other medical conditions, says Dr. Starling.
Other preventive treatments for migraine
Onabotulinum toxin A (Botox) may be a treatment option for people with chronic migraine. People with this condition experience 15 or more migraine headache days a month for more than three months. First approved by the FDA in 2010, these injections temporarily paralyze muscle and nerve activity in the forehead, scalp, neck and shoulders thought to contribute to migraine.
“The medication reduces the activity of pain receptors and blocks pain signals,” says Dr. Starling.
On the downside, each set of injections cost several thousand dollars and are required every few months.
Read more: Questions and answers about botox injections
Neuromodulation devices also offer promise as a migraine treatment. These noninvasive devices are placed on the head or body for a few minutes, daily. Some studies show they can help with both the severity and frequency of migraine attacks.
Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission.
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