From the Guidelines
The recommended first-line prophylactic medication for migraines is typically candesartan, telmisartan, erenumab, fremanezumab, or galcanezumab, as they have been shown to be effective in preventing episodic or chronic migraine. According to the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1, these medications are recommended for the prevention of migraine. Candesartan and telmisartan are angiotensin II receptor blockers that have been shown to be effective in reducing migraine frequency, while erenumab, fremanezumab, and galcanezumab are monoclonal antibodies that target the calcitonin gene-related peptide (CGRP) receptor, which is involved in the pathophysiology of migraine.
- Other options for migraine prevention include:
- Lisinopril, an angiotensin-converting enzyme (ACE) inhibitor
- Oral magnesium
- Topiramate, an anticonvulsant
- Propranolol, a beta-blocker
- Valproate, an anticonvulsant
- Memantine, an N-methyl-D-aspartate (NMDA) receptor antagonist
- Atogepant, a CGRP receptor antagonist
- OnabotulinumtoxinA injection, a botulinum toxin injection
It's essential to note that the choice of medication should be individualized based on the patient's specific needs and medical history. Patients should be aware that prophylactic medications may take 4-8 weeks to show benefit, and side effects should be monitored. The treatment plan should be regularly reevaluated to ensure the medication is effective and to minimize potential side effects.
From the Research
First-Line Prophylactic Medication for Migraines
The following medications are recommended as first-line agents for migraine prevention:
- Propranolol
- Timolol
- Amitriptyline
- Divalproex
- Sodium valproate
- Topiramate 2
Efficacy of Topiramate
Topiramate has been shown to be effective in reducing headache frequency and improving quality of life in patients with episodic migraine:
- A 26-week, randomized, double-blind, placebo-controlled study found that topiramate reduced mean monthly migraine frequency by about 1.2 attacks per 28 days compared to placebo 3
- A meta-analysis of 17 unique trials found that topiramate reduced headache frequency by about 1.2 attacks per 28 days and approximately doubled the proportion of responders relative to placebo 4
- A retrospective chart review found that topiramate yielded significant reductions in migraine frequency, migraine severity, number of headache days/month, and use of abortive medications in patients with transformed migraine and episodic migraine 5
Comparison with Other Medications
Topiramate has been compared to other medications in several studies:
- A meta-analysis found that topiramate was no more effective than amitriptyline, flunarizine, or propranolol in reducing headache frequency, but had a slight significant advantage over valproate 4
- A study found that topiramate was effective as a preventive therapy for patients with migraine, with a significant reduction in mean monthly migraine frequency compared to placebo 3
Adverse Events
Topiramate has been associated with several adverse events, including: