From the Guidelines
The most effective preventative medications for migraines are CGRP antagonists, such as erenumab (70-140 mg monthly injection) and fremanezumab (225 mg monthly injection), which have been shown to reduce migraine frequency and severity with fewer side effects compared to traditional treatments. According to the most recent and highest quality study 1, these medications are recommended for the prevention of episodic and chronic migraine. Other options, such as beta-blockers (e.g., propranolol, metoprolol), antidepressants (e.g., amitriptyline), and anticonvulsants (e.g., topiramate, valproate), may also be effective, but their use should be individualized based on patient comorbidities, side effect profiles, and preferences.
- Key considerations for preventative treatment include:
- Migraine frequency and severity
- Presence of aura or other neurological symptoms
- Comorbid medical conditions (e.g., hypertension, depression)
- Patient preferences and values
- Potential side effects and interactions with other medications
- Lifestyle modifications, such as regular sleep, stress management, and trigger avoidance, should accompany medication therapy to optimize treatment outcomes.
- The choice of medication and treatment duration should be reassessed regularly, typically every 2-3 months, to ensure adequate response and minimize adverse effects.
- As noted in 1, the use of a headache diary can help determine treatment efficacy, identify analgesic overuse, and follow up on migraine progression.
- It is essential to consider the economic burden of migraine treatment and prescribe less costly recommended medications when possible, as suggested in 1.
From the FDA Drug Label
The initial oral dose is 80 mg propranolol hydrochloride extended-release capsules once daily. The usual effective dose range is 160 to 240 mg once daily. The dosage may be increased gradually to achieve optimal migraine prophylaxis If a satisfactory response is not obtained within four to six weeks after reaching the maximal dose, propranolol hydrochloride extended-release capsules therapy should be discontinued.
The recommended preventative medication for migraines is propranolol with an initial dose of 80 mg once daily, and a usual effective dose range of 160 to 240 mg once daily 2.
- The dosage may be increased gradually to achieve optimal migraine prophylaxis.
- If a satisfactory response is not obtained within four to six weeks after reaching the maximal dose, therapy should be discontinued.
From the Research
Recommended Preventative Medications for Migraines
The following medications are recommended for migraine prevention:
- Propranolol 3, 4
- Timolol 3, 4
- Amitriptyline 3, 4
- Divalproex sodium 3, 4
- Sodium valproate 3, 4
- Topiramate 5, 3, 6, 4
- Gabapentin 3, 4
- Naproxen sodium 3
- Botulinum toxin 3
- Metoprolol 4
- Nadolol 4
- Candesartan 4
- Petasites (butterbur) 4
- Riboflavin 4
- Coenzyme Q10 4
- Magnesium citrate 4
Dosages for Migraine Prevention
- Topiramate: 100 mg/day is the optimum dosage in terms of efficacy and tolerability 5, 6
- Propranolol: dosage not specified in the studies, but recommended as a first-line agent 3, 4
- Other medications: dosages not specified in the studies, but recommended based on evidence and expert consensus 3, 4
Principles of Preventive Treatment
- Choice of preventive treatment should be based on the presence of comorbid and coexistent illness, patient preference, reproductive potential and planning, and best available evidence 4
- Treatment efficacy should be assessed after 2 or 3 months, and in case of failure or poor tolerance, another treatment should be started 7
- If the treatment is successful, it should be continued for 6 to 12 months, and then tapered off 7