Migraine prophylaxis: Newer options for migraine management

Newer prophylactics being explored for their potential role in migraine management include monoclonal antibodies, botulinum toxin, nonsteroidal anti-inflammatory drugs (NSAIDs), serotonin antagonists,...
Last update4th Dec 2020

Newer prophylactics being explored for their potential role in migraine management include monoclonal antibodies, botulinum toxin, nonsteroidal anti-inflammatory drugs (NSAIDs), serotonin antagonists, trigger point therapy, nerve blocks, and others.

Monoclonal antibodies as prophylaxis for migraines

Research on the biochemistry of migraines has focused on a protein in the brain, calcitonin gene-related peptide (CGRP). When CGRP is given to people who are susceptible to migraines, an attack is triggered, and CGRP is elevated during an attack in patients with migraines. It has also been shown that blocking this peptide from exerting its effect will prevent migraine.

These findings have led to the development of monoclonal antibodies against CGRP which affect the peptide or block its action.

Currently, three monoclonal antibodies (Erenumab, Galcanezumab, and Fremanezumab) have been approved for use: one binds and inactivates the CGRP molecule and two block its receptor.

Use of any of these antibodies significantly reduces the amount of headache days, the severity, and duration of headache. These agents are generally safe and do not have widespread immune effects.

Botulinum toxin as prophylaxis for migraines

Onabotulinum toxin type A (otherwise known as Botox) is approved by the FDA for chronic migraine in which there are > 15 days of headache a month. Injections of a small amount of toxin are placed in the frontalis, temporalis, nasalis, and corrugator muscles as well as into the posterior strap muscles. The dose is typically 155 mouse units every 12 weeks.

Potential side effects are facial muscle weakness and asymmetry, generalized weakness, swallowing dysfunction, and local pain.

Nonsteroidal anti-inflammatory drugs (NSAIDs) as prophylaxis for migraines

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen and ketoprofen have also been used for prophylaxis. In some headache centers, NSAIDs are used along with riboflavin and magnesium.

Serotonin antagonists as prophylaxis for migraines

Methysergide and methylergometrine are anti-serotonin drugs, or serotonin antagonists, from the ergot family. They cannot be used long term due to the potential development of pulmonary fibrosis.

Although cyproheptadine is an antihistamine, it has actions as a serotonin antagonist. Cyproheptadine is often used in children, but in adults it tends to be too sedating.

Trigger point therapy as prophylaxis for migraines

When the physical exam indicates a musculoskeletal contribution to the headaches, trigger point injections or dry needling might be considered.

Nerve blocks as prophylaxis for migraines

Occipital nerve blocks with steroids and lidocaine, or a longer acting agent, might prove helpful in some cases.

Other novel prophylactic treatments for headaches

Other treatments have been tried with varying success:

  • Acupuncture
  • Behavioral training for relaxation
  • Biofeedback
  • Cervical facet blocks
  • Cognitive behavioral therapy (CBT)
  • Physical therapy
  • Craniosacral manipulation
  • Neurostimulation using noninvasive transcranial magnetic stimulation
  • Trigeminal nerve stimulation using the CEFALY device (used for both prevention and acute treatment)

That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.

Recommended reading

  • Blumenfeld, AM. 2018. Botox for chronic migraine: Tips and tricks. Practical Neurology17: 27–36. https://practicalneurology.com
  • Halker Singh, RB, Starling, AJ, and VanderPluym, J. 2019. Migraine acute therapies. Practical Neurology17: 63–67. https://practicalneurology.com
  • Krel, R and Mathew, PG. 2019. Procedural treatments for headache disorders. Practical Neurology17: 76–79. https://practicalneurology.com
  • Mauskop, A. 2012. Nonmedication, alternative, and complementary treatments for migraine. Continuum (Minneap Minn)18: 796–806. PMID: 22868542
  • Motwani, M and Kuruvilla, D. 2019. Behavioral and integrative therapies for headache. Practical Neurology17: 85–89. https://practicalneurology.com
  • Natekar, A, Malya, S, Yuan, H, et al. 2019. Migraine preventative therapies in development. Practical Neurology17: 54–57. https://practicalneurology.com
  • Parikh, SK and Silberstein, SD. 2018. Calcitonin gene-related peptide monoclonal antibodies. Practical NeurologyFeb: 20–22. https://practicalneurology.com
  • Rizzoli, PB. 2012. Acute and preventative treatment of migraine. Continuum (Minneap Minn)18: 764–782. PMID: 22868540
  • Tepper, SJ and Tepper, DE. 2018. Neuromodulation and headache. Practical Neurology17: 42–45. https://practicalneurology.com

About the author

Robert Coni, DO EdS
Neurohospitalist, Medical Director and Coordinator at the Grand Strand Medical Center, and Clinical Assistant Professor at the University of South Carolina.
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