From the Guidelines
First-line treatments for migraine prophylaxis include beta-blockers (propranolol 40-240 mg/day, metoprolol 50-200 mg/day), antiepileptics (topiramate 25-200 mg/day, valproate 500-1500 mg/day), and certain antidepressants (amitriptyline 10-150 mg/day). These medications are typically started at low doses and gradually increased over 4-8 weeks to minimize side effects. Treatment should continue for at least 3-6 months before assessing effectiveness, with success defined as a 50% reduction in migraine frequency.
Key Considerations
- Second-line options include calcium channel blockers (verapamil 120-360 mg/day), angiotensin pathway modulators (candesartan 8-32 mg/day, lisinopril 10-20 mg/day), and newer CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) for refractory cases.
- Medication choice should be individualized based on comorbidities, potential side effects, and patient preferences. For example, propranolol should be avoided in patients with asthma, while topiramate may benefit those with concurrent obesity.
- Prophylactic treatment is generally recommended when patients experience four or more migraine days monthly, have significant disability despite acute treatments, or when acute medications are contraindicated or causing medication overuse headache, as noted in studies such as 1.
Treatment Approach
- The treatment approach should involve educating patients about their condition and involving them in the management plan, as emphasized in 1.
- Regular follow-up is necessary to assess the effectiveness of the treatment and to make adjustments as needed, considering the patient's response and any side effects, as discussed in 1.
From the Research
First-Line Treatment Options
- Beta-blockers such as propranolol, timolol, and metoprolol are recommended as first-line agents for migraine prevention 2, 3, 4
- Anticonvulsants like divalproex, sodium valproate, and topiramate are also considered first-line treatments 2, 3, 4
- Amitriptyline is another first-line option, particularly useful in patients with comorbid tension-type headache, depression, and sleep disorders 5, 6, 3
Second-Line Treatment Options
- Gabapentin and naproxen sodium have fair evidence of effectiveness and can be considered as second-line agents 2, 5
- Venlafaxine, atenolol, and nadolol are probably effective but should be used as second-line therapy 4
- Botulinum toxin has demonstrated fair effectiveness, but further studies are needed to define its role in migraine prevention 2
- Other second-line options include lisinopril, candesartan, and magnesium, although evidence for these is limited 6, 4
Non-Pharmacological Treatments
- Relaxation techniques, bio-feedback, cognitive behavioral therapy, and acupuncture are supported by some evidence and can be used as non-pharmacological treatments 5, 6, 4
- Lifestyle modifications, such as maintaining a regular sleep schedule, meals, exercise, and stress management, are also important in migraine prevention 6