Preventative Treatment Options for Migraines
First-line preventative medications for migraine include propranolol, timolol, amitriptyline, divalproex sodium, sodium valproate, and topiramate, with selection based on patient-specific factors and comorbidities. 1
Indications for Preventative Therapy
Preventative treatment should be considered when:
- Two or more attacks per month producing disability lasting 3+ days per month
- Contraindication to or failure of acute treatments
- Use of abortive medication more than twice per week
- Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, migrainous infarction)
- Medication overuse headache (MOH) 1
First-Line Pharmacologic Options
Beta Blockers
- Propranolol: 80-240 mg/day
- Timolol: 20-30 mg/day
- Metoprolol: Evidence supports efficacy
- Nadolol: Evidence supports efficacy
Anticonvulsants
- Topiramate: First choice for patients with obesity due to association with weight loss
- Divalproex sodium: 500-1500 mg/day
- Sodium valproate: 800-1500 mg/day
- Important: Discuss teratogenic effects with women of childbearing potential; recommend effective birth control and folate supplementation 1
Antidepressants
- Amitriptyline: 30-150 mg/day
- Preferred for patients with comorbid depression or sleep disturbances 1
Other First-Line Options
- Candesartan: Evidence supports efficacy
Specific Options for Chronic Migraine
For patients with chronic migraine (15+ headache days per month with headaches lasting 4+ hours):
- Topiramate: First choice due to lower cost
- OnabotulinumtoxinA (Botox): FDA-approved for chronic migraine prevention
- Warning: Monitor for rare but serious side effects including difficulty swallowing, speaking, or breathing 2
- CGRP monoclonal antibodies: Effective when other preventives have failed 1
Non-Pharmacologic Options
Lifestyle modifications: Should be recommended for all migraine patients
- Identify and avoid triggers
- Regular sleep schedule
- Regular meals
- Hydration
- Stress management
Nutraceuticals with evidence of efficacy:
- Coenzyme Q10
- Magnesium citrate
- Riboflavin (vitamin B2)
- Feverfew (modest efficacy)
Behavioral interventions:
- Biofeedback
- Cognitive-behavioral therapy
- Relaxation techniques
Treatment Algorithm
- Assess migraine frequency and disability
- If prevention indicated, select agent based on:
- Comorbidities (e.g., depression, obesity, hypertension)
- Potential side effects
- Patient preferences
- Pregnancy potential (avoid valproate/topiramate in women planning pregnancy)
- Start with low dose and titrate slowly until clinical benefit achieved or limited by side effects
- Allow adequate trial period (2-3 months) before determining efficacy
- If first agent fails, try another first-line medication from a different class
- For chronic migraine, consider topiramate first, then onabotulinumtoxinA or CGRP antibodies if topiramate fails
Important Clinical Pearls
- Medication overuse must be addressed before starting preventive therapy
- Begin preventive medications at low doses and titrate slowly to minimize side effects
- Clinical benefit may take 2-3 months to manifest
- Consider tapering or discontinuing treatment after a period of stability
- Educate patients on realistic expectations for preventive therapy
- Monitor for medication-specific adverse effects (e.g., cognitive effects with topiramate, weight gain with amitriptyline)
Remember that the goal of preventive therapy is to reduce attack frequency, severity, and associated disability while minimizing side effects and improving quality of life 3.