What are the recommended treatments for migraine headaches prophylaxis?

Migraine Headache Prophylaxis

For migraine prophylaxis, CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) or angiotensin receptor blockers (candesartan/telmisartan) are recommended as first-line preventive treatments, particularly for patients with high-frequency episodic migraines. 1

First-Line Preventive Medications

Beta-Blockers

• Propranolol: 80-240 mg/day 1
• Timolol: 20-30 mg/day 1

Antidepressants

• Amitriptyline: 30-150 mg/day 1
  • Contraindicated in heart failure and glaucoma 1

Anticonvulsants

• Divalproex sodium: 500-1,500 mg/day 1
• Sodium valproate: 800-1,500 mg/day 1
• Topiramate: 100 mg/day (optimal dosage) 2, 3
  • Only anticonvulsant with proven efficacy in randomized, placebo-controlled trials for chronic migraine 2
  • Reduces migraine days by approximately 3.5 days per month in chronic migraine 4
  • Common side effects include paresthesia, cognitive dysfunction, and weight loss 3

CGRP Monoclonal Antibodies

• Erenumab, fremanezumab, galcanezumab 1
• Recommended for high-frequency episodic migraines with complex visual aura, photosensitivity, and severe pain 1

OnabotulinumtoxinA (Botox)

• The only FDA-approved therapy specifically for prophylaxis of headache in adults with chronic migraine 2
• Administered by a neurologist or headache specialist 2
• Safety warning: May cause problems with swallowing, speaking, or breathing; these problems can occur hours to weeks after injection 5
• Contraindicated in patients with neuromuscular disorders 5

Treatment Selection Algorithm

1. For patients with chronic migraine (≥15 headache days/month):

   • First choice: OnabotulinumtoxinA (Botox) 2, 1
   • Alternative: Topiramate 100 mg/day 2, 4

2. For patients with episodic migraine with comorbid hypertension:

   • First choice: Candesartan/telmisartan 1
   • Alternative: Propranolol 80-240 mg/day 1

3. For patients with episodic migraine without comorbidities:

   • First choice: CGRP monoclonal antibodies 1
   • Alternatives: Propranolol, timolol, amitriptyline, or divalproex sodium 1

Monitoring and Evaluation

• Maintain a headache diary to track frequency, severity, and medication use 2, 1
• Evaluate treatment response after 2-3 months of optimized preventive therapy 1
• Treatment failure is defined as less than 50% reduction in monthly migraine days, no significant improvement in headache-related disability, or intolerable side effects 1

Lifestyle Modifications

• Identify and manage modifiable risk factors and triggers, including:
  • Obesity
  • Medication overuse
  • Caffeine use
  • Obstructive sleep apnea
  • Psychiatric comorbidities
  • Stress 2
• Regular aerobic exercise, consistent sleep schedule, adequate hydration, and regular meals 1
• Oral magnesium (400-600 mg daily) is the most evidence-supported supplement 1

Important Considerations and Cautions

• Medication overuse can contribute to the transformation from episodic to chronic migraine 2
• Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 1
• Triptans are contraindicated in patients with history of coronary artery disease, stroke, TIA, hemiplegic or basilar migraine, peripheral vascular disease, or uncontrolled hypertension 1
• For OnabotulinumtoxinA, monitor for spread of toxin effects which may cause botulism-like symptoms 5

When to Refer to a Specialist

• Refractory headaches not responding to multiple treatment options 1
• Presence of red flags: sudden severe headache, headache with fever, stiff neck, confusion, or neurological symptoms 1

By implementing this evidence-based approach to migraine prophylaxis, clinicians can significantly reduce the frequency and severity of migraine attacks, improving patients' quality of life and reducing disability.