What are the recommended medications and dosages for migraine prevention?

From the Guidelines

For migraine prevention, the most effective medications include propranolol (80-240 mg daily), amitriptyline (30-150 mg daily), divalproex sodium (500-1500 mg daily), and sodium valproate (800-1500 mg daily), as recommended by the American College of Physicians 1.

Key Considerations

• The choice of medication should be individualized based on comorbidities, potential side effects, patient preference, and cost considerations.
• Preventive treatment should typically be started at a low dose and gradually increased, with an adequate trial lasting at least 2-3 months.
• Success is generally defined as a 50% reduction in migraine frequency.
• Lifestyle modifications, including regular sleep, meals, exercise, and stress management, should accompany pharmacological prevention.

Medication Options

• Beta-blockers: propranolol (80-240 mg daily), metoprolol (50-200 mg daily)
• Antiepileptic drugs: topiramate (25-100 mg daily), valproate (500-1500 mg daily)
• Tricyclic antidepressants: amitriptyline (10-150 mg at bedtime)
• Calcium channel blockers: flunarizine (5-10 mg daily)
• CGRP monoclonal antibodies: erenumab (70-140 mg), fremanezumab (225 mg monthly), galcanezumab (120 mg monthly)
• Botulinum toxin A: 155-195 units every 12 weeks for chronic migraine

Important Notes

• The use of a headache diary may help to determine treatment efficacy, identify analgesic overuse, and follow up on migraine progression.
• Consider reevaluating the balance of benefits, harms, and costs of preventive treatment with the patient after a reasonable trial period.
• Certain behavioral interventions, such as cognitive behavioral therapy, relaxation training, or mindfulness-based treatment, may decrease the frequency of migraine headaches.

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 medication for migraine prevention is propranolol. The initial dosage is 80 mg once daily, and the 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, therapy should be discontinued 2.

From the Research

Medications for Migraine Prevention

The following medications are recommended for migraine prevention:

• Propranolol, timolol, amitriptyline, divalproex, sodium valproate, and topiramate are considered first-line agents 3
• Gabapentin and naproxen sodium have fair evidence of effectiveness 3
• Botulinum toxin has demonstrated fair effectiveness, but further studies are needed to define its role in migraine prevention 3
• Metoprolol, nadolol, and candesartan have strong evidence to support their use in migraine prevention 4
• Petasites (butterbur), riboflavin, coenzyme Q10, and magnesium citrate received a strong recommendation for use from the Canadian Headache Society 4

Dosages and Treatment Principles

• The dose of 100 mg/daily of topiramate is considered ideal in terms of efficacy, but doses as low as 50 mg/daily can show some efficacy and improve tolerability 5
• Treatment efficacy should be assessed after 2 or 3 months, and in case of failure or poor tolerance, another treatment should be started 6
• Doses should be increased gradually to reach the recommended daily dose, only if tolerance permits 6
• If the treatment is successful, it should be continued for 6 to 12 months, and then tapered off 6

Choice of Preventive Treatment

• The 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
• The decision to treat with drugs and the choice of a prophylactic drug are made together with the patient, taking into account possible side effects and contraindications, characteristics of the migraine attacks, and associated morbidities and possible interactions with abortive medications 6