What are prophylactic medications for migraine (prophylaxis) headaches?

From the Guidelines

Prophylactic migraine medication should be considered in patients who are adversely affected by migraine on ≥2 days per month despite optimized acute treatment. When selecting a prophylactic medication, the following options can be considered:

• First-line medications: beta blockers (atenolol, bisoprolol, metoprolol or propranolol), topiramate or candesartan, as recommended by 1
• Second-line medications: flunarizine, amitriptyline or (in men) sodium valproate, as suggested by 1
• Third-line medications: CGRP monoclonal antibodies, which can be considered for patients who do not respond to first-line or second-line treatments, as indicated by 1 Other treatment options, such as neuromodulatory devices, biobehavioural therapy and acupuncture, can be used as adjuncts to acute and preventive medication or as stand-alone preventive treatment when medication is contraindicated, according to 1. Key considerations when initiating prophylactic treatment include:
• Starting with a low dose and gradually increasing to minimize side effects
• Allowing 2-3 months at therapeutic doses to properly assess effectiveness, aiming for at least a 50% reduction in headache frequency
• Accompanying medication therapy with lifestyle modifications, including regular sleep, meals, exercise, and stress management, for optimal results.

From the Research

Prophylactic Migraine Medication

Prophylactic migraine medication is used to reduce the frequency and severity of migraine headaches. The following medications are commonly used for migraine prophylaxis:

• Beta-blockers such as propranolol, metoprolol, and timolol 2, 3, 4
• Anticonvulsants such as topiramate, divalproex, and valproate 2, 3, 4, 5
• Antidepressants such as amitriptyline and venlafaxine 2, 3, 6, 4
• Botulinum toxin type A (Botox) 3, 6
• Calcitonin gene-related peptide receptor antagonists 3

First-Line Medications

First-line medications for migraine prophylaxis include:

• Propranolol 2, 3, 4
• Metoprolol 3, 4
• Topiramate 2, 3, 4, 5
• Divalproex 2, 3, 4
• Valproate 2, 3, 4
• Calcitonin gene-related peptide receptor antagonists 3

Second-Line Medications

Second-line medications for migraine prophylaxis include:

• Amitriptyline 2, 3, 6, 4
• Venlafaxine 3, 6, 4
• Gabapentin 2, 6, 4
• Naproxen sodium 2
• Botulinum toxin type A (Botox) 3, 6

Alternative Therapies

Alternative therapies for migraine prophylaxis include:

• Feverfew 2, 3, 6
• Magnesium 2, 3, 6, 4
• Riboflavin (vitamin B2) 2, 6, 4
• Coenzyme Q10 2, 4
• Acupuncture 3, 6
• Cognitive behavioral therapy 3
• Exercise 3
• Relaxation techniques 5