What are the recommended treatments for migraine prevention?

Migraine Prevention Management

For migraine prevention, first-line pharmacologic treatments include beta-blockers, anticonvulsants (topiramate), antidepressants (amitriptyline), and CGRP pathway antagonists, with treatment selection guided by patient comorbidities, potential side effects, and cost considerations. 1, 2

Initial Approach to Migraine Prevention

When to Consider Preventive Treatment

• Consider pharmacologic prevention for patients with:
  • Severe debilitating headaches despite adequate acute treatment
  • Inability to tolerate or contraindications to acute treatments
  • Using acute treatments more frequently than recommended (risk of medication overuse headache)
  • 4 or more migraine days per month
  • Significant disability despite appropriate acute treatment 1, 2

Non-Pharmacologic Interventions (First Step)

Before initiating pharmacologic prevention:

• Identify and address modifiable triggers:

  • Maintain regular sleep patterns and adequate hydration
  • Eat regular meals to avoid hypoglycemia
  • Engage in regular aerobic exercise (30 minutes most days)
  • Implement stress management techniques 1, 2

• Consider behavioral interventions:

  • Cognitive behavioral therapy
  • Relaxation training
  • Mindfulness-based treatment 1

Pharmacologic Prevention Options

First-Line Treatments

Based on the most recent evidence and guidelines:

1. Beta-blockers

   • Propranolol (80-240 mg/day)
   • Timolol (20-30 mg/day)
   • Particularly useful in patients with comorbid hypertension or tachycardia 2

2. Anticonvulsants

   • Topiramate (50-200 mg/day)
     • May lead to weight loss
     • Consider cognitive side effects
     • Teratogenic (requires effective contraception in women of childbearing potential) 1, 2
   • Valproic acid/Divalproex sodium (500-1500 mg/day)
     • Teratogenic (requires effective contraception in women of childbearing potential) 2

3. Antidepressants

   • Amitriptyline (30-150 mg/day)
     • Useful for comorbid tension-type headache, depression, and sleep disorders
     • Consider anticholinergic side effects 2

4. CGRP Pathway Antagonists

   • Monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab)
   • Gepants (rimegepant, atogepant)
   • Galcanezumab has demonstrated significant reduction in monthly migraine headache days compared to placebo 3, 4

Second-Line Options

If first-line treatments are ineffective or not tolerated:

• ACE inhibitor (lisinopril)
• ARBs (candesartan, telmisartan)
• SSRIs (fluoxetine) 1

Nutraceuticals and Supplements

Consider for patients preferring non-prescription options:

• Magnesium (400-600 mg daily)
• Riboflavin/Vitamin B2 (400 mg daily)
• Coenzyme Q10
• Feverfew 2

Implementation Strategy

1. Start Low, Go Slow

   • Begin pharmacologic prevention at a low dose
   • Gradually increase until desired outcomes are achieved 1

2. Adequate Trial Period

   • Allow 2-3 months to assess efficacy before determining treatment failure
   • Consider earlier switch if adverse effects occur 1, 2

3. Monitoring and Follow-up

   • Use headache diaries to track frequency, severity, and medication use
   • Evaluate for medication overuse (limit acute medications to ≤10 days/month) 2

4. Treatment Combinations

   • If sequential monotherapies are ineffective, consider combinations of first-line drugs before moving to second-line options 5

Special Populations

Children and Adolescents

• Consider ibuprofen for acute treatment
• For prevention, discuss evidence for amitriptyline combined with cognitive behavioral therapy, topiramate, and propranolol 1

Pregnancy and Breastfeeding

• Discuss adverse effects of medications during pregnancy and lactation
• Magnesium may be particularly useful during pregnancy 1, 5

Treatment Selection Considerations

When choosing between equally effective preventive treatments:

• Consider cost as a key factor in prioritizing different classes
• Assess patient's economic circumstances and personal preferences
• Evaluate comorbid conditions that may influence treatment choice:
  • Hypertension → beta-blockers, lisinopril, candesartan
  • Overweight → topiramate (may cause weight loss)
  • Depression/anxiety → amitriptyline
  • Sleep disorders → amitriptyline 1, 2

Common Pitfalls to Avoid

1. Inadequate trial duration - Allow sufficient time (2-3 months) before determining treatment failure

2. Medication overuse - Limit acute medications to prevent medication overuse headache

3. Starting at full dose - Begin at low doses and titrate up to minimize side effects

4. Neglecting lifestyle factors - Address sleep, diet, exercise, and stress management alongside pharmacologic treatment

5. Overlooking comorbidities - Select preventive medications that may benefit coexisting conditions

By following this structured approach to migraine prevention, clinicians can help patients achieve significant reductions in migraine frequency and severity, improving quality of life and reducing disability.