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Changing the course of migraine at the Ottawa Headache Centre
Changing the course of migraine at the Ottawa Headache Centre
Migraine and other primary headache disorders are neurologic conditions of brain excitability. When attacks are frequent or disabling, preventive treatment becomes a cornerstone of care.
Preventive therapy is taken regularly — not during an attack — with the goal of reducing how often headaches occur, how severe they are, and how disruptive they become over time. For many patients, thoughtful preventive treatment significantly improves quality of life and reduces reliance on acute medications.
At the Ottawa Headache Centre, prevention is structured, individualized, and guided by subspecialty expertise.
The specialists at the Ottawa Headache Centre have developed medication handouts about what to know about migraine medications: feel free to use them and share them with your doctor.
When should you consider migraine preventive treatment
When should you consider migraine preventive treatment
High frequency
of attacks
High frequency
of attacks
Experiencing 4 or more attacks per month is a sign you may benefit from preventives.
Acute medications
are not enough
Acute medications
are not enough
Relying on frequent use of rescue medications or not having a rescue medication that works.
Attacks are
disabling
Attacks are
disabling
Attacks that greatly limit your function in spite of rescue medications.
The Ottawa Headache Centre tiered approach to migraine prevention
The Ottawa Headache Centre tiered approach to migraine prevention
Our principles for migraine prevention
Our principles for migraine prevention
For migraine prevention there is not a one-size-fits-all prescription. We look at your biology, your history, and your lifestyle to build a multi-layered defense.
1. The foundation: lifestyle
1. The foundation: lifestyle
Before we look at prescriptions, we stabilize the "migraine brain" by managing triggers through the SEEDS framework:
Sleep hygiene (consistent wake/sleep times).
Exercise (steady, non-strenuous movement).
Eat (healthy, balanced, and avoid sugar crashes).
Diary (tracking triggers and frequency).
Stress management (regulating your triggers and their impact on your nervous system).
2. Oral preventive medications
2. Oral preventive medications
These are daily medications intended to "calm" the overactive nerves involved in migraine. They usually fall into four categories:
Blood pressure meds: Often the first line of defense.
Antidepressants: Used for their pain-modulating properties, not just mood.
Anticonvulsants: Helping to stabilize nerve excitability.
Nutraceuticals: Evidence-based supplements like magnesium, riboflavin (B2), and coenzyme Q10.
3. Advanced therapies
3. Advanced therapies
When oral medications aren't enough, or the side effects are too high, we move to targeted therapies that specifically block the migraine pathway.
Botox® for chronic migraine: A gold-standard treatment for patients with 15+ headache days a month. It involves precise injections every 12 weeks to block pain signaling.
CGRP antagonists: The first class of drugs designed from scratch specifically for migraine prevention.
Nerve blocks: In-office injections to provide both immediate relief and reduce long-term migraine pain and associated symptoms.
Prevention is a marathon, not a sprint. Most preventive treatments require 8 to 12 weeks of consistent use before we can accurately judge their success. Patience is the hardest part of the treatment, but it is the key to long-term stability.
Our philosophy
Our philosophy
Preventive treatment is not about “doing more.”
It is about doing what is appropriate — at the right time — for the right patient.
Some patients do very well with simple oral strategies. Others require advanced biologic therapies.
Many require careful titration and reassessment.
Our role is to guide that process with clarity and expertise.
Your next steps for migraine prevention
Your next steps for migraine prevention
If you are a new patient, ensure your doctor has sent the necessary referral forms.
Learn more about:
Start a headache diary: We cannot treat what we cannot measure. Explore our trusted tools and consider using a headache tracker before your appointment.
Common questions about migraine preventive medications
Common questions about migraine preventive medications
General questions about oral preventives for migraine
General questions about oral preventives for migraine
Why do I have to take preventive medications daily if I don't have migraine attacks every day?
Why do I have to take preventive medications daily if I don't have migraine attacks every day?
Migraine is a chronic condition that is marked by flares or attacks.
The goals of preventive medications are to:
Reduce the frequency of attacks
Reduce the severity or intensity of the attacks
Reduce the duration of attacks
Make the migraine attacks more vulnerable to acute medications (i.e., easier to treat)
These medications are not effective "as needed".
What are common oral preventive medications?
What are common oral preventive medications?
There are many non-specific oral preventive medications that can be used to prevent migraine. Among them, some of the more common ones include:
Amitriptyline / Nortriptyline
Candesartan
Metoprolol or propranolol
Topiramate
Why are some preventive medications started at low doses?
Why are some preventive medications started at low doses?
To reduce side effects and allow the body to adjust.
How long should a preventive medication be tried before deciding it failed?
How long should a preventive medication be tried before deciding it failed?
Usually 8 weeks at a therapeutic dose.
Most insurer providers request a minimum trial of 3 months before approving coverage for migraine-specific preventive medications.
Are there vitamins or supplements that can help prevent migraine?
Are there vitamins or supplements that can help prevent migraine?
Yes.
Some nutraceuticals (vitamins and supplements) have evidence for migraine prevention and are commonly recommended, especially for people who:
Prefer non-prescription options
Have mild to moderate migraine
Want to add something low-risk to prescription prevention
Are pregnant or planning pregnancy (some options are safer)
Options include:
Magnesium 400-600 mg orally daily
Riboflavin (Vitamin B2) 400 mg orally daily
Coenzyme Q10 (CoQ10) 200-300 mg orally daily
These supplements work gradually and usually take 8–12 weeks to show benefit.
Questions about CGRP antagonists for migraine prevention
Questions about CGRP antagonists for migraine prevention
What is CGRP?
What is CGRP?
CGRP (calcitonin gene-related peptide) is a naturally neuropeptide protein involved in:
Pain transmission
Sensitization of migraine pathways
Migraine attack generation
Vasodilation
During migraine attacks, CGRP levels increase and contribute to headache pain and associated symptoms.
How do CGRP antagonists prevent migraine?
How do CGRP antagonists prevent migraine?
CGRP antagonists block CGRP or its receptor, reducing baseline migraine sensitivity and preventing attacks before they start.
What are the different CGRP antagonists available in Canada for migraine prevention?
What are the different CGRP antagonists available in Canada for migraine prevention?
CGRP antagonists are divided into two broad classes:
CGRP monoclonal antibodies (monthly or quarterly injectable medications)
Gepants (daily oral medications)
CGRP monoclonal antibodies for migraine prevention
CGRP monoclonal antibodies for migraine prevention
There are several CGRP monoclonal antibodies available. They differ mainly in how they are given.
Targets CGRP
Given by intravenous infusion
Administered every 3 months
Blocks the CGRP receptor
Self-administered injection
Given once monthly
Targets CGRP
Self-administered injection
Given monthly or quarterly
Targets CGRP
Self-administered injection
Given monthly
Also approved for episodic cluster headache
Gepants for migraine prevention
Gepants for migraine prevention
Taken once daily for migraine prevention
Used to reduce migraine frequency
Not used to treat acute attacks
How are CGRP monoclonal antibodies taken?
How are CGRP monoclonal antibodies taken?
CGRP monoclonal antagonists can be administered:
Monthly subcutaneous auto-injection (erenumab, galcanezumab)
Monthly or every 3 months subcutaneous auto-injection (fremanezumab)
IV infusion every 3 months (eptinezumab)
Do CGRP monoclonal antibodies affect the immune system?
Do CGRP monoclonal antibodies affect the immune system?
They do not suppress the immune system and do not meaningfully increase infection risk.
Studies have found a small signal that some people may be at a higher risk of urinary tract infections or nasopharyngeal infections.
Can I receive vaccines while on CGRP therapy?
Can I receive vaccines while on CGRP therapy?
Yes.
Vaccinations are safe while on CGRP therapy.
Why must CGRP monoclonal antibodies be stopped before pregnancy?
Why must CGRP monoclonal antibodies be stopped before pregnancy?
They remain in the body for a long time and are safety data in pregnancy are lacking.
They should be stopped at least 6 months before conception.
How does atogepant (Qulipta®) work?
How does atogepant (Qulipta®) work?
Atogepant (Qulipta®) blocks CGRP daily, preventing migraine from starting.
It works quickly and clears quickly if stopped.
Questions about Botox® for migraine prevention
Questions about Botox® for migraine prevention
How does Botox® work for migraine?
How does Botox® work for migraine?
Botox® injected using a validated migraine protocol prevents release of migraine-related chemicals (including CGRP) and reduces the brain's sensitization to headache.
How often is Botox® given?
How often is Botox® given?
Every 12 weeks.
Does Botox® affect the immune system?
Does Botox® affect the immune system?
No.
Botox ® acts locally and does not affect immune function.
Is Botox® safe in pregnancy?
Is Botox® safe in pregnancy?
While Botox® is not formally recommended by guidelines in pregnancy, many headache specialists are comfortable using it in pregnancy. This is informed by large registry studies showing safety.
Our specialist can help you make an informed decision.
Can oral preventives be combined with CGRP therapy or Botox®?
Can oral preventives be combined with CGRP therapy or Botox®?
Yes.
While many patients only need a CGRP antagonist or Botox®, others remain on a oral preventive alongside CGRP therapy or Botox®.
Questions about menstrual-related migraine prevention
Questions about menstrual-related migraine prevention
What is menstrual-related migraine?
What is menstrual-related migraine?
Migraine that predictably occurs around menstruation due to estrogen changes.
What is mini-prophylaxis?
What is mini-prophylaxis?
Short-term preventive treatment used only during the high-risk menstrual window.
What medications are used for mini-prophylaxis?
What medications are used for mini-prophylaxis?
Depending on the person:
NSAIDs (e.g., naproxen)
Triptans taken daily during the window, generally started 2-3 days before menses (e.g., frovatriptan, which is a long-acting triptan
Gepants
Disclaimer
Disclaimer
This material is provided for educational purposes and does not replace independent clinical judgment or institutional protocols. Management decisions remain the responsibility of the treating clinician.
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