What are the medications designed to prevent migraines?

Medications Designed to Prevent Migraines

Medications designed to prevent migraines include beta-blockers (propranolol, timolol, metoprolol), anticonvulsants (topiramate, divalproex sodium, sodium valproate), antidepressants (amitriptyline), CGRP antagonists (erenumab, galcanezumab), and several other drug classes with varying levels of evidence. 1, 2, 3

First-Line Preventive Medications

Beta-Blockers

• Propranolol: 80-240 mg/day
• Timolol: 20-30 mg/day
• Metoprolol: Effective for migraine prevention
• Atenolol: Limited evidence but may be effective
• Avoid in patients with asthma, bradycardia, or heart block 1

Anticonvulsants

• Topiramate: Strong evidence for efficacy
• Divalproex sodium: 500-1500 mg/day
• Sodium valproate: 800-1500 mg/day
• Valproate is contraindicated in women of childbearing potential due to teratogenicity 1

Antidepressants

• Amitriptyline: 30-150 mg/day
• Avoid in patients with cardiac conduction disorders or urinary retention 1

CGRP Antagonists

• Erenumab (Aimovig): FDA-approved for preventive treatment of migraine in adults 2
• Galcanezumab (Emgality): Reduces monthly migraine headache days by 4.3-4.7 days compared to 2.3-2.8 days with placebo 3

Second-Line Preventive Medications

Calcium Channel Blockers

• Flunarizine: 10 mg/day (proven efficacy but not available in all countries)
• Verapamil: Limited evidence of modest effect 4

Angiotensin Pathway Blockers

• Candesartan: Effective for migraine prevention 1
• Lisinopril: Limited evidence but may be effective 5

NSAIDs

• Naproxen: Modest effect on headache prevention
• Common side effects include gastrointestinal symptoms (3-45% of patients) 4

Serotonergic Agents

• Methysergide: Strong evidence for efficacy but requires drug holidays due to risk of fibrosis
• Time-released DHE: Strong support from placebo-controlled trials 4

Nutraceuticals and Supplements

• Magnesium: Fair evidence for modest efficacy
• Riboflavin (Vitamin B2): Fair evidence for modest efficacy
• Coenzyme Q10: Limited evidence but may be effective
• Feverfew: Fair evidence in certain circumstances 4, 1

Practical Approach to Migraine Prevention

1. Start preventive treatment when:

   • Migraines occur ≥2 days per month
   • Attacks significantly impact quality of life despite acute treatment 1

2. Medication initiation:

   • Start with lowest effective dose
   • Titrate slowly to minimize side effects
   • Allow 2-3 months for full clinical benefit 1

3. Monitoring and follow-up:

   • Assess response within 2-4 weeks of medication changes
   • Monitor for medication overuse headaches
   • Consider tapering or discontinuing after a period of stability 1

Special Considerations

• Pregnancy planning: Avoid valproate in women of childbearing potential
• Cardiovascular risk: Monitor blood pressure in patients using certain preventives
• Comorbidities: Choose preventives that may treat comorbid conditions (e.g., depression, hypertension)
• Combination therapy: Behavioral therapy with preventive medication may achieve additional improvement 1

Emerging Treatments

• Botulinum toxin: Demonstrated fair effectiveness for chronic migraine prevention, though further studies are needed 5
• CGRP pathway antagonists: Newer class of medications specifically designed for migraine prevention with promising efficacy data 2, 3

The choice of preventive medication should be based on efficacy evidence, side effect profile, comorbidities, and patient-specific factors. Regular monitoring and dose adjustments are essential to optimize treatment outcomes.