Migraine Prophylaxis Treatment Recommendations
For migraine prophylaxis, first-line medications include propranolol (80-240 mg/day), timolol (20-30 mg/day), amitriptyline (30-150 mg/day), divalproex sodium (500-1500 mg/day), sodium valproate (800-1500 mg/day), and topiramate (100 mg/day). 1
When to Consider Preventive Therapy
Preventive therapy should be initiated when:
- Migraines occur ≥2 times per month
- Attacks are prolonged and disabling
- Quality of life is reduced between attacks 1
The goal of preventive therapy is to achieve at least a 50% reduction in attack frequency, with an adequate trial requiring 6-8 weeks at therapeutic doses to properly assess effectiveness 1.
First-Line Pharmacological Options
Beta-Blockers
- Propranolol (80-240 mg/day): FDA-approved for migraine prophylaxis with strong evidence supporting its efficacy 1, 2
- Timolol (20-30 mg/day): Also recommended by the American Academy of Neurology 1
Anticonvulsants
- Topiramate (100 mg/day): Highly effective for migraine prevention with strong evidence 1, 3
- Start at 25 mg/day and titrate by 25-50 mg weekly to target dose
- Has shown significant reduction in monthly migraine days compared to placebo (3.5 days vs 0.2 days) 3
- Divalproex sodium (500-1500 mg/day) or Sodium valproate (800-1500 mg/day) 1
- Caution: Avoid in female adolescents and women of childbearing potential due to teratogenic risk 1
Antidepressants
- Amitriptyline (30-150 mg/day): Effective for migraine prevention 1
Second-Line Options
CGRP Antagonists
- Erenumab, fremanezumab, or galcanezumab: Strongly recommended for patients with inadequate response to first-line treatments 1
- Ubrogepant and rimegepant: Newer options with "weak for" recommendation 1
Complementary Approaches
Consider adding these evidence-based complementary treatments:
- Magnesium supplements: 400-600 mg daily 1
- Riboflavin: 400 mg daily 1
- Coenzyme Q10 1
- Feverfew: May reduce pain intensity and associated symptoms 1, 4
Non-Pharmacological Approaches
Implement these lifestyle modifications for all patients:
- Regular sleep schedule
- Consistent meal times
- Adequate hydration
- Regular physical activity
- Stress management techniques
- Identification and avoidance of personal triggers 1
Evidence-based behavioral interventions include:
Important Considerations and Monitoring
Medication Overuse Prevention
- Limit acute medication use to prevent medication overuse headache:
- NSAIDs ≤15 days/month
- Triptans ≤10 days/month 1
Special Populations
- Pregnancy: Use caution with preventive medications; many are contraindicated
- Cardiovascular risk: Be cautious with beta-blockers in patients with bradycardia or heart block
- Diabetes: Monitor blood glucose more frequently when initiating new medications 1
- Obesity: Consider topiramate which may assist with weight loss as a beneficial side effect 1
Monitoring Effectiveness
- Use a headache diary to track:
- Frequency and duration of headaches
- Pain intensity and characteristics
- Associated symptoms
- Triggers
- Medication use and response 1
Treatment Algorithm
- Initial Assessment: Determine if patient meets criteria for preventive therapy (≥2 migraines/month, disabling attacks, reduced quality of life)
- First-Line Selection: Choose from propranolol, timolol, amitriptyline, divalproex/valproate, or topiramate based on:
- Comorbidities (avoid valproate in women of childbearing potential)
- Side effect profile (consider topiramate if weight loss desired)
- Patient preferences
- Titration: Start at low dose and gradually increase to therapeutic range
- Evaluation: Assess effectiveness after 6-8 weeks at therapeutic dose
- Adjustment: If <50% reduction in attack frequency:
- Try another first-line agent OR
- Consider CGRP antagonists as second-line therapy
- Complementary Approaches: Add magnesium, riboflavin, CoQ10 as adjuncts
- Lifestyle Modifications: Implement consistently throughout treatment
Remember that the target is a 50% reduction in attack frequency, and an adequate trial requires 6-8 weeks at therapeutic doses to properly assess effectiveness.