Combination therapies for difficult migraines

We always try to use one preventive drug or Botox for the treatment of frequent or very severe migraine headaches.  However, it is not unusual to go through several drugs and not find one which works well and does not cause side effects.  Under those circumstances combining two drugs or Botox injections with a daily drug with is the next step.  A study to be presented at the 62nd annual meeting of the American Academy of Neurology looked at 92 migraine patients who did not respond to a single drug.  86 of these patients found relief from a combination of either topiramate (Topamax) with verapamil (Calan, Verelan), or amitriptyline (Elavil) and a beta blocker (such as Inderal or propranolol, or atenolol).  Combining two medications makes sense is they have different mechanism of action.  For example topiramate is an epilepsy drug, while verapamil is a blood pressure medicine in the category of calcium channel blockers.  Amitriptyline is an antidepressant with pain-relieving properties, while beta-blockers are blood pressure drugs.  At times we combine two epilepsy drugs or two anti-depressants if they work in two distinct ways.

  1. GiGi says: 05/24/20106:32 pm


    Not sure where you live but I highly recommend seeing Dr. Mauskop if you can. I have been a patient for over 10 years, I still suffer from migraines buy Dr. Mauskop is very patient and always helpful by suggesting we try new therapies. I tried Botox and at first it did not help, however now it really has made my migraines less frequent and much more tolerable. Nerve block injections help as well. Don’t give up hope and try and be patient, trying to find relief can be frustating and time consuming but worth it even if only a temporary fix.

    Good Luck, GiGi

  2. Harvey Karten says: 05/01/20105:40 pm


    Have you tried the gold standard, Imitrex Statdose injectables? Imitrex, which now is sold in its generic version, sumatriptan succinate, does not prevent headaches but if it works, it aborts headaches within 20 minutes of the time you inject yourself with a simple “gun.” The Rx is expensive: the generic is $60 to $70 per shot, which would come to up to $280 a week if you take the drug 4 times weekly. I’m covered by insurance, but I still pay $4,500 a year, but then again I use the drug even more than four times weekly. Some people have insurance that allows them to pay no more than $300 a year–e.g. New York City active teachers (which I was before retirement).

  3. Dr. Mauskop says: 04/18/201010:44 pm

    I would suggest asking your doctor to check your RBC magnesium and CoQ10 levels and then exploring with your doctor a combination of two medications with different mechanism of action you might have tried and trying medications that you might have not tried because they are not used frequently. These would include phenelzine, memantine, acetazolamide, montelukast, protriptyline, and tizanidine. The most important step though is to try cognitive therapy, specifically ACT – acceptance and commitment therapy ( see my brief blog post: ).

  4. Jennifer O'Neill says: 04/18/20105:17 am

    I am a 36 year old female who has suffered from chronic migraines for over 10 years. I get between 3 to 4 a week and am currently on disability and unable to work. Actually, I’m not really able to do much of anything. I have worked with many Nuerologists and specialists over the years, taken every preventative medication under the sun, have tried bio-feedback, accupuncture, holistic medicine and basically everything I can get my hands on and can financially afford. I have offered myself up for research studies all with no real sucess. I have kept a migraine diary for almost 5 years. No one seems to be able to help me. Luckily I was able to try Botox through a research study and was given 2 rounds of injections lasting 6 months. I say luckily not because it worked, but because it was free. I was sure this was going to be my answer and yet it wasn’t. I have tried Topamax but it made me literally psychotic. Very scary. I felt compelled to respond to your blog because after reading it I was sobbing. To feel trapped at 36 because of my migraines is utterly unbearable. My quality of life is diminishing and I feel helpless. So what is someone like me supposed to do now?

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