What are the options for migraine (headache disorder) prophylaxis (preventive treatment)?

From the Guidelines

Migraine prophylaxis should be considered in patients who are adversely affected by migraine on ≥2 days per month despite optimized acute treatment, with first-line medications including beta blockers, topiramate, or candesartan. When evaluating patients for migraine prophylaxis, it is essential to consider the frequency and severity of their migraines, as well as their response to acute treatments [ 1 ]. The decision to start prophylaxis should be based on the presence of disabling migraines, defined as those that interfere with daily activities, despite optimized acute treatment.

Key Considerations for Migraine Prophylaxis

• First-line medications: beta blockers (such as propranolol or metoprolol), topiramate, or candesartan [ 1 ]
• Second-line medications: flunarizine, amitriptyline, or sodium valproate (in men) [ 1 ]
• Third-line medications: CGRP monoclonal antibodies, such as erenumab, fremanezumab, or galcanezumab [ 1 ]
• Non-pharmacological approaches: regular sleep schedules, stress management, and trigger avoidance should accompany medication

Initiating Migraine Prophylaxis

When initiating prophylaxis, it is crucial to start with a low dose and gradually increase over 4-8 weeks to minimize side effects. A successful trial requires at least 2-3 months of treatment, with the goal of reducing migraine frequency by at least 50% [ 1 ]. Patient education and engagement in the formulation of a management plan are also essential, as they can help establish realistic expectations and track their progress [ 1 ].

Monitoring and Adjusting Treatment

Regular follow-up and monitoring of treatment response are necessary to adjust the treatment plan as needed. This may involve switching to a different medication or adding non-pharmacological approaches to optimize treatment outcomes [ 1 ]. By prioritizing patient-centered care and evidence-based treatment, healthcare providers can help improve the quality of life for individuals with migraines.

From the FDA Drug Label

Migraine: Propranolol hydrochloride extended-release capsules are indicated for the prophylaxis of common migraine headache The propranolol is indicated for migraine prophylaxis.

• The drug is used to prevent common migraine headache.
• It is not used to treat a migraine attack that has already started 2

From the Research

Migraine Prophylaxis Medications

• First-line agents for migraine prevention include:
  • Propranolol, timolol, amitriptyline, divalproex, sodium valproate, and topiramate 3
  • Beta-adrenoceptor blockers, flunarizine, topiramate, and valproic acid 4
  • Divalproex, topiramate, metoprolol, propranolol, and timolol 5
• Second-line medications include:
  • Gabapentin, venlafaxine, atenolol, and nadolol 5
  • Venlafaxine, gabapentin, naproxen, butterbur root, riboflavin, and magnesium 6
• Anti-epileptic drugs effective for migraine prophylaxis:
  • Topiramate and valproate 7
  • Gabapentin or lamotrigine for those with allodynia or frequent aura 7

Non-Pharmacological Treatments

• Lifestyle advice, including regular sleep, meals, exercise, and stress management 4
• Relaxation techniques, bio-feedback, cognitive behavioral therapy, and acupuncture 4, 5, 6
• Identifying and managing environmental, dietary, and behavioral triggers 5

Considerations for Treatment

• Choice of prophylactic drugs depends on efficacy, co-morbidity, side effects, availability, and cost 6
• Potential serious side effects of anti-epileptic drugs, particularly for women of childbearing potential 7
• Importance of monitoring patients closely for adverse effects, especially with certain medications like botulinum toxin and valproate 3, 4