What medications can be used for the maintenance of migraines?

Medications for Migraine Prophylaxis

For migraine prophylaxis, first-line medications include propranolol, timolol, amitriptyline, divalproex sodium, sodium valproate, topiramate, and CGRP monoclonal antibodies (erenumab, fremanezumab, or galcanezumab). 1, 2

First-Line Prophylactic Medications

Strong Recommendations

• CGRP Monoclonal Antibodies: Erenumab, fremanezumab, or galcanezumab are strongly recommended for prevention of episodic or chronic migraine 1
• Beta-blockers:
  • Propranolol (80-240 mg/day) 1, 2
  • Timolol (20-30 mg/day) 1, 2

Additional First-Line Options

• Anticonvulsants:
  • Divalproex sodium (500-1,500 mg/day) 1, 2
  • Sodium valproate (800-1,500 mg/day) 1, 2
  • Topiramate - effective for both episodic and chronic migraine 1, 2
• Antidepressants:
  • Amitriptyline (30-150 mg/day) - particularly beneficial for patients with comorbid depression or sleep disturbances 1, 2

Second-Line Prophylactic Medications

• IV Eptinezumab - suggested for prevention of episodic or chronic migraine 1
• Lisinopril - suggested for prevention of episodic migraine 1
• Oral magnesium - suggested for prevention of migraine 1, 2
• Memantine - suggested for prevention of episodic migraine 1
• Atogepant - suggested for prevention of episodic migraine 1
• OnabotulinumtoxinA - suggested for prevention of chronic migraine only (not recommended for episodic migraine) 1, 2

Indications for Preventive Therapy

Preventive treatment should be considered when:

• Two or more migraine attacks per month with disability for three or more days per month 1
• Use of rescue medication more than twice a week 1
• Failure of acute treatments or contraindications for such treatments 1
• Presence of uncommon migraine conditions (e.g., prolonged aura, migrainous infarction, hemiplegic migraine) 1

Medication Selection Considerations

1. Comorbidities: Select medications that may benefit both migraine and existing conditions

   • Example: Propranolol for patients with hypertension or tachycardia 2
   • Amitriptyline for patients with depression or sleep disturbances 2

2. Contraindications:

   • Avoid triptans in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or risk for heart disease 1
   • Use caution with propranolol in patients with asthma, diabetes, or heart block 3

3. Pregnancy considerations:

   • Acetaminophen is preferred for acute treatment during pregnancy 2
   • Preventive treatments should be avoided if possible during pregnancy 2

Medications NOT Recommended

• Gabapentin - specifically recommended against for prevention of episodic migraine 1
• AbobotulinumtoxinA or OnabotulinumtoxinA - recommended against for episodic migraine (though onabotulinumtoxinA is recommended for chronic migraine) 1

Treatment Monitoring and Adjustment

• Allow 2-3 months to properly assess preventive efficacy before determining treatment failure 2
• Use headache diaries to track frequency, severity, and medication use 2
• Start at a low dose and gradually increase until desired outcomes are achieved 2
• Consider earlier medication switch if adverse effects occur 2
• Limit acute medications to ≤10 days per month to prevent medication overuse headache 2

Acute Treatment Options

While this question focuses on prophylaxis, it's worth noting that appropriate acute treatment is also essential:

• First-line: NSAIDs (ibuprofen 400-800mg, naproxen 500-550mg) 2
• Second-line: Triptans (sumatriptan, rizatriptan, zolmitriptan, etc.) 1, 2
• Combination therapy: Aspirin-acetaminophen-caffeine 1
• Newer options: Rimegepant or ubrogepant 1

Common Pitfalls to Avoid

• Medication overuse: Limit acute medications to ≤10 days per month to prevent medication overuse headache 2
• Inadequate trial period: Allow sufficient time (2-3 months) to assess efficacy of preventive medications 2
• Inappropriate expectations: Set realistic goals of 50% reduction in frequency rather than complete elimination 2
• Neglecting non-pharmacological approaches: Regular sleep, meals, hydration, stress management, and exercise can complement medication therapy 2

Remember that the goal of preventive therapy is to reduce migraine frequency, severity, and headache-related distress, ultimately improving quality of life and preventing progression to chronic migraines.