What are the recommended treatments for migraine prophylaxis?

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 considering treatment options, the following medications are recommended:

• Beta blockers (atenolol, bisoprolol, metoprolol or propranolol) as first-line medications 1
• Topiramate as a first-line medication 1
• Candesartan as a first-line medication 1
• Flunarizine, amitriptyline, or sodium valproate as second-line medications 1
• CGRP monoclonal antibodies as third-line medications 1 It is essential to note that preventive treatment should be tailored to the individual patient, taking into account the frequency and severity of their migraines, as well as any comorbid conditions or contraindications to certain medications. Additionally, lifestyle modifications such as maintaining regular sleep patterns, staying hydrated, exercising regularly, managing stress, and identifying and avoiding personal triggers are crucial in managing migraines. Neuromodulatory devices, biobehavioural therapy, and acupuncture can also be considered as adjuncts to acute and preventive medication or as stand-alone preventive treatment when medication is contraindicated 1.

From the FDA Drug Label

In a 34-week, placebo-controlled, 4-period, dose-finding crossover study with a double-blind randomized treatment sequence, 62 patients with migraine received propranolol 20 to 80 mg 3 or 4 times daily The headache unit index, a composite of the number of days with headache and the associated severity of the headache, was significantly reduced for patients receiving propranolol as compared to those on placebo The recommended treatment for migraine prophylaxis is propranolol at a dose of 20 to 80 mg, 3 or 4 times daily, as it has been shown to significantly reduce the headache unit index compared to placebo 2.

• Key points:
  • Dose: 20 to 80 mg, 3 or 4 times daily
  • Efficacy: significantly reduced headache unit index
  • Study design: 34-week, placebo-controlled, 4-period, dose-finding crossover study with a double-blind randomized treatment sequence

From the Research

Migraine Prophylaxis Treatments

The following are recommended treatments for migraine prophylaxis:

• First-line agents:
  • Propranolol 3, 4, 5
  • Timolol 3, 4, 5
  • Amitriptyline 3, 6, 4, 5
  • Divalproex 3, 4, 5
  • Sodium valproate 3, 6, 4, 5
  • Topiramate 3, 6, 4, 7, 5
  • Metoprolol 4, 5
• Second-line agents:
  • Gabapentin 3, 6, 7, 5
  • Naproxen sodium 3, 6
  • Venlafaxine 6, 4
  • Botulinum toxin type A 3
  • Butterbur root 6, 5
  • Riboflavin 6, 4, 5
  • Magnesium 6, 4, 5
• Non-pharmacological treatments:
  • Relaxation techniques 4
  • Bio-feedback 6, 4
  • Cognitive behavioral therapy 6, 4
  • Acupuncture 6

Considerations for Treatment Choice

The choice of prophylactic treatment should be based on:

• Efficacy 6, 5
• Co-morbidity 6, 5
• Side effects 6, 7, 5
• Availability and cost 6
• Reproductive potential and planning 7, 5