What is the indication for daily preventative medication in patients with frequent and severe migraine attacks?

Indications for Migraine Preventive Medication

Daily preventive medication is indicated for patients who experience migraines ≥2 times per month, have prolonged and disabling attacks, or experience reduced quality of life between attacks. 1

Primary Indications for Preventive Therapy

• Frequency-based criteria:

  • Migraines occurring ≥2 times per month 1
  • Headache days totaling ≥8 days per month 2
  • Frequent attacks that significantly impact daily functioning

• Severity-based criteria:

  • Prolonged and disabling attacks 1
  • Attacks that cause substantial impairment despite acute treatment
  • Reduced quality of life between attacks 1

• Treatment-related criteria:

  • Risk of medication overuse headache
  • Contraindication, failure, or overuse of acute medications
  • Patient preference for preventive approach

Medication Selection Algorithm

1. First-line preventive options (based on highest quality evidence):

   • Beta-blockers: Propranolol (80-240 mg/day), Timolol (20-30 mg/day) 1, 3
   • Anticonvulsants: Topiramate (100 mg/day), Divalproex sodium (500-1500 mg/day) 1
   • Antidepressants: Amitriptyline (30-150 mg/day) 1

2. Second-line options:

   • Venlafaxine, Atenolol, Nadolol 2
   • Angiotensin receptor blockers: Candesartan, Telmisartan 1

Important Clinical Considerations

• Therapeutic trial duration: Allow 6-8 weeks at therapeutic dose to assess effectiveness 1

• Target outcome: Aim for at least 50% reduction in attack frequency 1

• Dosing optimization: Start at lower doses and titrate up to minimize side effects

  • Example: For propranolol, start at 80 mg daily and increase gradually to 120-160 mg as needed 3
  • For topiramate, 100 mg/day is the optimal dose for efficacy and tolerability 4, 5

• Medication overuse prevention: Limit acute medications to prevent medication overuse headache:

  • NSAIDs ≤15 days/month
  • Triptans ≤10 days/month 1

Special Populations and Contraindications

• Pregnancy considerations: Avoid valproate and topiramate due to teratogenic effects 1
• Women with migraine with aura: Avoid combined hormonal contraceptives with estrogens due to increased stroke risk 1
• Cardiovascular risk: Use caution with triptans in patients with cardiovascular risk factors 1

Complementary Approaches

• Magnesium (400-600 mg daily), Riboflavin (400 mg daily), and Coenzyme Q10 supplements may be considered as adjunctive treatments 1
• Cognitive behavioral therapy, relaxation techniques, and regular exercise have proven efficacy in migraine management 1

Common Pitfalls to Avoid

• Inadequate dosing: Using subtherapeutic doses (e.g., amitriptyline at 10 mg is subtherapeutic; doses of 30-100 mg are needed) 1
• Premature discontinuation: Not allowing sufficient time (6-8 weeks) to assess effectiveness 1
• Overlooking lifestyle factors: Not addressing sleep, meal timing, hydration, physical activity, and stress management 1
• Monotherapy fixation: Not optimizing current medications before switching to alternatives 1

Remember that the goal of preventive therapy is to reduce migraine frequency, severity, and headache-related distress while improving quality of life and preventing progression to chronic migraines 2.