Migraine headache are severe headaches which most typically are one-sided, throbbing headaches often accompanied by nausea, sensitivity to light, and occasionally vomiting.  Different types of treatment are used to treat migraine and to prevent migraines. 

The preferred treatment for preventing migraines has been beta-blockers such as propranolol (80-320 mg/day in divided doses 2-4 times a day) and timolol (10-15 mg twice a day), as well as metoprolol, nadolol, and atenolol.  These are very inexpensive medications most often used to treat high blood pressure.  The second most sensible treatment is amitriptyline, a tricyclic antidepressant, at 10-150 mg once a day at bedtime.  A calcium channel blocker such as sustained release verapamil (generic Calan SR) has also been effective and inexpensive.  Unfortunately, calcium channel blockers don't help you live longer.  The anti-depressant venlafaxine also has one favorable study.  A useful supplement for migraines is magnesium 250 mg. twice a day.  It may cause soft stools and occasional diarrhea.  Melatonin is another worthwhile intervention to try.

Two newer treatments have been the antiepileptic drugs: 

1) valproic acid (generic Depakene), or divalproex (Depakote).  Depakene is modest in price which Depakote costs about $73/month for 250-500 mg twice a day.  It can cause considerable weight gain, as well as nausea, tiredness, tremor, hair loss, and rarely liver failure and pancreatitis. 

2) topiramate (Topamax) at 50 mg twice a day.  Topamax is a very expensive patented medication with a high percentage of individuals suffering side-effects, some of which can be severe.  These include tingling extremities, slowed thinking, difficulty concentrating, interference with memory, taste aversion, tiredness, kidney stones, and fractures.  Some patients lose weight averaging 3%.

An ACE inhibitor, butterbur, CoQ10, 5-HTP, and botox injections have also been used successfully for migraines with the first four inexpensive.  

My favorites would be propranolol, ACE inhibitors enalapril or captopril, CoQ10, and amitriptyline, all of which have a chance of lengthening longevity as well as helping headaches.

To treat migraines once they develop, narcotics have been shown inferior.  The triptan family of medicines is most popular but requires a prescription or emergency room visit.  Taking over-the-counter acetaminophen 500 mg with aspirin 500 mg and caffeine 130 mg (two APC tablets) actually did better than the triptans if taken early according to a large study.

Review Conclusions: Sufficient evidence and consensus exist to recommend propranolol, timolol, amitriptyline, divalproex, sodium valproate, and topiramate as first-line agents for migraine prevention. There is fair evidence of effectiveness with gabapentin and naproxen sodium. Botulinum toxin also has demonstrated fair effectiveness, but further studies are needed to define its role in migraine prevention. Limited evidence is available to support the use of candesartan, lisinopril, atenolol, metoprolol, nadolol, fluoxetine, magnesium, vitamin B2 (riboflavin), coenzyme Q10, and hormone therapy in migraine prevention. Data and expert opinion are mixed regarding some agents, such as verapamil and feverfew; these can be considered in migraine prevention when other medications cannot be used. Evidence supports the use of timed-release dihydroergotamine mesylate, but patients should be monitored closely for adverse effects. Medications for migraine prophylaxis. Modi S, et al. East Carolina University, Greenville, North Carolina 27834, USA. . Am Fam Physician 2006 Jan 1;73(1):72-8.

5-HTP Some Benefit; Propranolol Did Better: In a DB PC trial of 39 migraine patients, after a placebo run-in of one month, the patients received either 5-hydroxytryptophan or propranolol for 4 months. The treatment with both substances resulted in a statistically significant reduction in frequency of migraine attacks. In the propranolol group the duration of the attacks and the number of analgesics used for treatment of the attacks were significantly reduced. Although propranolol, which is considered a reference for the interval treatment of migraine, is more effective, 5-hydroxytryptophan is a possible alternative for many patients. Comparison of the effect of 5-hydroxytryptophan and propranolol in the interval treatment of migraine. Maissen CP, Ludin HP. Kantonsspital St. Gallen. Schweiz Med Wochenschr. 1991 Oct 26;121(43):1585-90 

ACE Inhibitor Helps Migraines:  The blood pressure medication linosopril (Prinivil) was found to help in 60 patient study with 1/3 getting benefit in a DB crossover study. BMJ 1/6/01. Ed: ACE inhibitors are great blood pressure medications.  Enalapril (Vasotec) and captopril (Capoten) are very inexpensive and just as good as linosopril.

APC Better than Triptans in Early Migraine: In a DB study of 171 adults with migraine attacks, taking two over-the-counter APC tablets was more effective than sumatriptan (P<0.05). Goldstein J, et al. San Francisco Headache Clinic. Headache, 2005;45:973-82.

Botox Very Successful: Reportedly helps up to 92% of those for whom meds ineffective. For headache treatment, it is injected into muscles around the eyes and forehead and sometimes the jaw. For patients whose headaches involve the entire head, additional injections are given in the upper back of the neck and shoulders. 134 patients with migraine headaches, tension headaches or chronic daily headaches (having a headache more than 15 days a month). A majority of the patients had already been treated with at least three headache medications without success. Patients had from one to four Botox treatments at three-month intervals. 84 percent of patients reported improvement. Among those who had four treatments, 92 percent reported improvement "good to excellent". There were significant improvements that appear to be progressive and may also be cumulative," said Troost. "I tell patients that it is important not give up if it has only a mild effect the first time. The second or third time it really seems to work better." Migraine headaches affect about 17 percent of women and 6 percent of men in the United States. About 5 percent of the population has chronic daily headache. Troost, Wake Forest, Amer Headache Society. 6/24/02 

Botox Helps in DB: A 12-week DB PC study of 60 patients with chronic tension and chronic migraine headaches of 200 units of botox found considerable subjective benefit and 24 vs. 33 headache days. Improvement seemed cumulative with second open trial injection. Botulinum toxin A for chronic daily headache: a randomized, placebo-controlled, parallel design study. Ondo W, Vuong K, Derman H. Cephalalgia. 2004 Jan;24(1):60-65 

Butterbur Helped Some for Migraine Prevention: A special root extract from the plant Petasites hybridus at 75 mg bid, 50 mg bid, or placebo bid was studied in a DB PC trial in 245 adults with 2-6 migraine attacks per month. Over 4 months of treatment, migraine attack frequency was reduced by 48% for Petasites extract 75 mg bid (p = 0.0012), 36% for Petasites extract 50 mg bid, and 26% for the placebo. Petasites hybridus root (butterbur) is an effective preventive treatment for migraine. Lipton RB, Gobel H, et al. Albert Einstein College of Medicine, Bronx, NY Neurology. 2004 Dec 28;63(12):2240-4

CoQ10 Helped Migraines: In a 3-month DB PC study of 42 migraine sufferers, those on CoQ10 (3 x 100 mg/day) had lower attack-frequency, headache-days and days-with-nausea in the third treatment month; 50%-responder-rate for attack frequency was 14% for placebo and 48% for CoQ10 (number-needed-to-treat: 3). Efficacy of coenzyme Q10 in migraine prophylaxis: A randomized controlled trial. Sandor PS, Di Clemente L, et al. University Hospital Zurich, Switzerland. Neurology. 2005 Feb 22;64(4):713-5.

Divalproex More Cost-Effective than Gabapentin or Topiramate: In the double-blind, placebo-controlled, clinical trials evaluated, three antiepileptic drugs were shown to be effective in migraine prevention. All three antiepileptic drugs had high costs per migraine reduced. Gabapentin was the most costly at $138.00 per migraine prevented, whereas the cost per migraine prevented with topiramate was $114.80 and with divalproex sodium was $48.00. For migraine prevention divalproex sodium became cost-effective with 10 migraines per month, whereas gabapentin and topiramate required considerably more migraines per month to be cost-effective. Cost-effectiveness of antiepileptic drugs in migraine prophylaxis. Adelman JU, Adelman LC, Von Seggern R. Headache 2002 Nov-Dec;42(10):978-83.

Melatonin: Migraine Victims Melatonin Falls Markedly with Nighttime Light: In a study of 12 women with familial migraines during headache-free periods vs. 12 controls, the nighttime melatonin production of the migraine sufferers was much more sensitive to light exposure (300 lx): -53.8 vs. 18.5 pg/h/ml, P<0.005; maximum of MLT suppression = -35.7 vs. - 6.7 pg/ml, P<0.05.  Melatonin secretion is supersensitive to light in migraine. Claustrat B, Brun J, et al. Institut Federatif de Neurosciences, Lyon, France. Cephalalgia. 2004 Feb;24(2):128-33

Melatonin as treatment for idiopathic stabbing headache. Rozen TD. Michigan Head-Pain and Neurological Institute, Ann Arbor. Neurology. 2003 Sep 23;61(6):865-6.

Melatonin, 3 mg Reported Effective for Migraine Prevention: Peres MF, Zukerman E, et al. Hospital Israelita Albert Einstein, Sao Paulo, Brazil Neurology. 2004 Aug 24;63(4):757. Ed: I don’t know any details of this report.  

Magnesium Appears to Help in Children and Adults: In a 16-week DB PC study of 118 children ages 3-17 with at least weekly, moderate-to-severe headache with a throbbing or pulsatile quality, associated anorexia/nausea, vomiting, photophobia, sonophobia, or relief with sleep, but no fever or evidence of infection, those given magnesium oxide (9 mg/kg per day by mouth divided 3 times a day with food) had a statistically significant decrease over time in headache frequency in the magnesium oxide group (P =.0037) but not in the placebo group (P =.086), although the slopes of these 2 lines were not statistically significantly different from each other (P =.88). The group treated with magnesium oxide had significantly lower headache severity (P =.0029) relative to the placebo group. Oral magnesium oxide prophylaxis of frequent migrainous headache in children: a randomized, double-blind, placebo-controlled trial. Wang F, et al. Kaiser Permanente, Hayward, CA, USA. Headache. 2003 Jun;43(6):601-10. Three DB studies in adults have similar findings, including one of menstrual migraines. Cephalalgia. 1996 Jun;16(4):257-63. Fortschr Med. 1994 Aug 30;112(24):328-30. Headache. 1991 May;31(5):298-301. Headache patients tend to be low in magnesium. However, magnesium supplementation was of no value in one DB and tended to cause diarrhea. Cephalalgia. 1996 Oct;16(6):436-40.

Propranolol and Topiramate Found Equally Effective: In a large DB study, propranolol 160 mg/day was as effective as topiramate 100 mg/day and both were better than placebo. H-C Diener et al. J Neurol 2004;291:2074.

Topiramate Better than Placebo: In two large DB PC studies of roughly 1000 patients in all, topiramate 100 mg/day reduced the average number of migraines per month from 5.6 to 3.4 while the placebo decreased them from 5.6 to 4.6, or about one headache per $200 spent. JL Brandes et al. JAMA 2004;291:965 and

Topiramate Helped Migraines Somewhat: In a 487-patient, 26-week DB PC study, topiramate 100 or 200 mg/day reduced headache frequency from 5.5 to 3.3 per month with both groups equal. Topiramate 50 mg/day worked less well and placebo reduced headaches to only 4.6 per month. Adverse events included paresthesia, fatigue, nausea, anorexia, and taste perversion. Topiramate in migraine prevention: results of a large controlled trial. Silberstein SD, Neto W, Schmitt J, Jacobs D; MIGR-001 Study Group. Thomas Jefferson University Hospital. Arch Neurol. 2004 Apr;61(4):490-5

Topiramate Helped Prevent Migraines: In a 16-week DB PC study of 72 migraine sufferers, topiramate 100 mg/day led to a significant 51% reduction in the frequency of migraines (from 5.26 to 2.60 in the last 4 weeks). Topiramate in migraine prophylaxis: a randomised double-blind versus placebo study. Mei D, Capuano A, et al. Universitario Agostino Gemelli, Rome, Italy. Neurol Sci. 2004 Dec;25(5):245-50. 

Venlafaxine Helped Migraines: In a 2-month DB PC study of 60 migraine patients without aura, venlafaxine XR 150 mg resulted in a lower rate of migrain attacks than placebo (P= .006). Patient satisfaction was better with both venlafaxine XR 75 and 150 (P= .001 at visit 2 and visit 6). 80% of patients on 75-mg and 88.2% on 150-mg rated treatment benefits as either good or very good. The efficacy and safety of venlafaxine in the prophylaxis of migraine. Ozyalcin SN, Talu GK, et al. Headache 2005;45:144-152.

For treatment of acute migraine headaches, the triptan family of medications has been by far the most popular.

Triptans for Migraines, Axert Cheapest: Six now available. Least expensive almotripton (Axert) 6.25 or 12.5 mg orally; can repeat once after 2 hours. $10.55 per headache. 70% relieved in 2 hr with 12.5 and 60% with 6.25 vs 38% placebo. similar to sumatriptan (Imitrex)($16.50 or $23 intranasal or $54 SC). No known interactions with MAOI, beta-blockers, or SSRIs which have interacted with other triptans. 

Metoclopromide Excellent Part of Migraine Treatment: In a meta-analysis of the 13 best studies, all DB PC emergency room trials of migraine sufferers and totaling 655 patients, intravenous metoclopramide (Systemic) was found to be three times as effective as placebo at relieving pain, an excellent response.  Metoclopramide relieves nausea and gastric stasis and has often been used with other migraine treatments including the triptans, chlorpromazine, and prochlorperazine. Migraines are common with 6% of men and 16% of women suffering them an average of 3 per month with 4-6 hours of bedrest per headache.  Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials. Ian Colman et al. Cambridge and Michigan State Universities. BMJ  12/11/2004;329:1369-1373. Ed: Oral metoclopramide (Reglan) is also available at very low cost. Narcotics have no place in the treatment of migraines. 

Heliobacter Pylori May Cause Migraines: Italian researchers found 18% chronic migraine infected with H. pylori. In a DB study of 130 treated for 3 weeks with antibiotics or antibiotics for 3 weeks plus Lactobacillus probiotics (yogurt or lactobacillus tablets) for one year found no difference in headaches at one month with very low relapse in group on lactobacillus and 50% without lactobacillus vs. 20% with still getting headaches at one year. AP Milan, 4/27/02.

Low Fat Diet Helps Migraines Considerably: High levels of blood lipids and high levels of free fatty acids are among the important factors involved in triggering migraine headaches. Under these conditions, platelet aggregability, which is associated with decreased serotonin and heightened prostaglandin levels, is increased. This leads to vasodilation, the immediate precursor of migraine headache. A high-fat diet is one factor that may directly affect this process. This study, undertaken to evaluate the impact of dietary fat intake on incidence and severity of migraine headache, was conducted over a 12-week period on 54 previously diagnosed migraine headache patients. During the first 28 days, the study subjects recorded all food consumption in a diet diary and maintained a headache diary. At the conclusion of this 28-day baseline period, subjects were individually counseled to limit fat intake to no more than 20 g/day. A 28-day run-in period was allowed for adaptation to the low-fat diet. Results are reported on the final 28-day postintervention period. Subjects significantly decreased the ingestion of dietary fat in grams between baseline (mean 65.9 g/day, p < 0.0001) and the postintervention period (mean 27.8 g/day). The decreased dietary fat intervention was associated with statistically significant decreases in headache frequency, intensity, duration, and medication intake (all p < 0.0001). There was a significant positive correlation between baseline dietary fat intake and headache frequency (r = .44, p = 0.02). This study indicates that a low-fat diet can reduce headache frequency, intensity, and duration and medication intake. J Womens Health Gend Based Med 1999 Jun;8(5):623-30