What are the maintenance medications for cephalalgia (headaches)?

From the Guidelines

Maintenance medications for cephalalgia, specifically migraines, should include first-line treatments such as beta-blockers like propranolol (40-160mg daily) or metoprolol (50-200mg daily), anticonvulsants like topiramate (25-100mg twice daily) or valproate (500-1000mg daily), and certain antidepressants like amitriptyline (10-75mg at bedtime) 1. For migraine prevention, these medications are recommended as they have shown efficacy in reducing headache frequency and severity.

• Beta-blockers, such as propranolol, are effective in reducing migraine frequency and are often used as first-line treatment.
• Anticonvulsants, like topiramate, have also been shown to be effective in preventing migraines.
• Antidepressants, such as amitriptyline, can be used for migraine prevention, especially in patients with comorbid depression or anxiety. Newer CGRP antagonists like erenumab (70-140mg monthly injection), fremanezumab, or galcanezumab offer excellent efficacy with fewer side effects but are more expensive 1. Lifestyle modifications should accompany medication therapy, including regular sleep patterns, stress management, avoiding triggers, and maintaining hydration. Patients should track headache frequency and severity to assess treatment effectiveness and discuss side effects with their healthcare provider. It is essential to consider preventive treatment in patients who are adversely affected by migraine on ≥2 days per month despite optimized acute treatment 1. Treatment should continue for at least 3-6 months before evaluating effectiveness, with the goal of reducing headache frequency by at least 50%. These medications work by modulating pain pathways, reducing neuronal hyperexcitability, or blocking inflammatory mediators. In addition to medication, consider neuromodulatory devices, biobehavioural therapy, and acupuncture as adjuncts to acute and preventive medication or as stand-alone preventive treatment when medication is contraindicated 1.

From the Research

Maintenance Medications for Cephalalgia (Headaches)

The following medications are used for the maintenance treatment of cephalalgia (headaches):

• Topiramate: effective in reducing headache days in chronic migraine 2, 3, 4
• Propranolol: a first-line agent for migraine prevention 5, 6
• Timolol: a first-line agent for migraine prevention 5
• Amitriptyline: a first-line agent for migraine prevention 5, 6
• Divalproex: a first-line agent for migraine prevention 5
• Sodium valproate: a first-line agent for migraine prevention 5
• Gabapentin: has fair evidence of effectiveness for migraine prevention 5
• Naproxen sodium: has fair evidence of effectiveness for migraine prevention 5
• Botulinum toxin: has demonstrated fair effectiveness, but further studies are needed to define its role in migraine prevention 5

Dosage and Administration

The dosage and administration of these medications vary:

• Topiramate: typically started at 25 mg/day and titrated upward to a maximum of 100 mg/day 2, 3, 4
• Propranolol: dosage varies depending on the patient's response and tolerance 5, 6
• Other medications: dosage and administration vary depending on the specific medication and patient's needs 5, 6

Efficacy and Safety

The efficacy and safety of these medications have been studied:

• Topiramate: has been shown to be effective in reducing headache days in chronic migraine, with a good safety profile 2, 3, 4
• Other medications: have varying levels of evidence for efficacy and safety, and should be chosen based on individual patient needs and circumstances 5, 6