What is the recommended prophylaxis treatment for migraines in women?

From the Guidelines

The recommended prophylaxis treatment for migraines in women includes several medication options, with first-line choices being beta-blockers, anticonvulsants, or tricyclic antidepressants, as well as newer options like erenumab, fremanezumab, or galcanezumab, which have shown strong evidence for prevention of episodic or chronic migraine 1. When considering prophylaxis treatment for migraines in women, it's essential to evaluate the frequency and severity of migraines, as well as their impact on quality of life.

• Prophylactic treatment is typically recommended when migraines occur more than 4 days per month, significantly impact quality of life, or when acute treatments are ineffective or contraindicated.
• The choice of medication should be individualized based on comorbidities, potential side effects, and patient preferences, with regular follow-up to assess effectiveness and adjust treatment as needed.
• Non-pharmacological approaches like regular sleep patterns, stress management, and trigger avoidance should accompany medication.
• For women of childbearing age who are not using reliable contraception, special consideration should be given as some medications like valproate are contraindicated due to teratogenic risks.
• Treatment should start at a low dose and gradually increase over 4-8 weeks to minimize side effects, with a full therapeutic trial lasting 2-3 months before determining efficacy. The most recent and highest quality study, published in 2025, suggests that clinicians use topiramate if a patient does not tolerate or inadequately responds to a trial or trials of a β-blocker (metoprolol or propranolol), the antiseizure medication valproate, the SNRI venlafaxine, or the TCA amitriptyline and a further trial with a CGRP antagonist-gepant (atogepant or rimegepant) or a CGRP-mAb (eptinezumab, erenumab, fremanezumab, or galcanezumab) 1. However, the 2024 guideline from the U.S. Department of Veterans Affairs and U.S. Department of Defense recommends candesartan or telmisartan for the prevention of episodic migraine, and erenumab, fremanezumab, or galcanezumab for the prevention of episodic or chronic migraine 1. Given the most recent and highest quality evidence, erenumab, fremanezumab, or galcanezumab are recommended as first-line options for the prevention of episodic or chronic migraine in women.

From the FDA Drug Label

Migraine: 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 recommended prophylaxis treatment for migraines in women is propranolol hydrochloride extended-release capsules, with an initial oral 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, propranolol hydrochloride extended-release capsules therapy should be discontinued.

From the Research

Recommended Prophylaxis Treatment for Migraines in Women

The recommended prophylaxis treatment for migraines in women includes:

• Beta-blockers, such as propranolol, which are particularly useful in patients with hypertension 3, 4, 5, 6
• Amitriptyline, which is useful in patients with associated depression and/or tension-type headache 3, 4, 7, 5, 6
• Valproate, which is considered if attacks are frequent 3, 4, 7, 5, 6
• Topiramate, which is a first choice for episodic as well as chronic migraine 5, 6
• Flunarizine, which has very good prophylactic properties, but is unavailable in many countries, including the United States 4, 6
• Lomerizine, which is recommended as the first-line prophylactic drug in Japan 7

Considerations for Prophylaxis Treatment

When choosing a prophylaxis treatment, the following considerations should be taken into account:

• The patient's preferences and headache profile 3, 4, 5
• The presence or absence of coexisting disorders, such as hypertension, depression, or tension-type headache 3, 4, 5, 6
• The potential side effects of the medication, such as weight gain or anticholinergic effects 3, 4, 6
• The patient's lifestyle, including regular sleep, meals, exercise, and management of stress 6

Alternative Treatment Options

Alternative treatment options for migraines in women include:

• Nutraceuticals, such as riboflavin, feverfew, butterbur, or coenzyme Q10 6
• Acupuncture, which may be another alternative, although controlled trials have failed to differentiate its effect from placebo 6
• Botulinum toxin A, which is not effective in the prophylaxis of episodic migraine 6