From the Guidelines
For migraine prevention, I recommend starting with a first-line medication such as candesartan, telmisartan, erenumab, fremanezumab, or galcanezumab, as these have strong evidence for reducing migraine frequency when taken daily 1. The choice of medication depends on the patient's medical history, comorbidities, and potential side effects.
- Candesartan and telmisartan are angiotensin II receptor blockers that have been shown to be effective in preventing migraines.
- Erenumab, fremanezumab, and galcanezumab are monoclonal antibodies that target the calcitonin gene-related peptide (CGRP) receptor, which is involved in the pathophysiology of migraines. Start at the lower dose and gradually increase over several weeks to minimize side effects. Preventive therapy is typically recommended when migraines occur more than 4 days per month, significantly impact quality of life, or when acute treatments like sumatriptan are insufficient or overused. The patient can continue using sumatriptan 50 mg as needed for breakthrough migraines while on preventive therapy. Preventive medications typically take 2-3 months to show full benefit, so patience is important. Lifestyle modifications including regular sleep, meals, exercise, stress management, and trigger avoidance should complement medication therapy. It is essential to educate the patient about the control of acute attacks and preventive therapy and engage them in the formulation of a management plan, as recommended by the clinical practice guideline for the management of headache 1.
From the Research
Migraine Prevention Medications
The patient is currently taking sumatriptan 50 mg for migraine and is looking for medications to prevent migraine. Based on the available evidence, the following medications have been shown to be effective for migraine prevention:
- Propranolol, timolol, amitriptyline, divalproex, sodium valproate, and topiramate are recommended as first-line agents for migraine prevention 2
- Gabapentin and naproxen sodium have fair evidence of effectiveness for migraine prevention 2
- Botulinum toxin has demonstrated fair effectiveness, but further studies are needed to define its role in migraine prevention 2
Considerations for Migraine Prevention
When considering medications for migraine prevention, the following factors should be taken into account:
- Efficacy: The medication's ability to reduce the frequency and severity of migraine attacks
- Co-morbidity: The presence of other medical conditions that may interact with the medication
- Side effects: The potential side effects of the medication and their impact on the patient's quality of life
- Availability and cost: The medication's availability and cost, including any potential insurance coverage or out-of-pocket expenses
Patient Preference for Sumatriptan Dose
A study on patient preference for oral sumatriptan dose found that:
- 35% of patients preferred the 100 mg dose
- 31% preferred the 50 mg dose
- 25% preferred the 25 mg dose 3 The study also found that the higher doses were more effective against migraine, but the 25 mg and 50 mg doses were better tolerated than the 100 mg dose.
Non-Pharmacological Treatments
Non-pharmacological treatments, such as relaxation techniques, bio-feedback, cognitive behavioral therapy, and acupuncture, may also be effective for migraine prevention, but require more specialist time or technical devices 4