What are the recommended treatments for prophylaxis of migraines?

Migraine Prophylaxis Treatment Recommendations

First-line preventive medications for migraine prophylaxis include propranolol (80-240 mg/day), topiramate (100 mg/day), and amitriptyline (30-150 mg/day), with selection based on patient-specific factors and comorbidities. 1

First-Line Pharmacological Options

Beta-Blockers

• Propranolol: 80-240 mg/day 1
  • FDA-approved for migraine prevention
  • Demonstrated efficacy in reducing migraine frequency 2
  • Consider in patients with comorbid hypertension
  • Contraindications: asthma, bradycardia, heart block

Anticonvulsants

• Topiramate: 100 mg/day 1
  • Start at 25 mg/day and titrate by 25-50 mg weekly to target dose
  • Optimal efficacy at 100 mg/day with significantly reduced migraine frequency 3
  • Common side effects: paresthesia (most common), cognitive dysfunction, weight loss 3, 4
  • Effective even in chronic migraine (≥15 headache days/month) 5

Antidepressants

• Amitriptyline: 30-150 mg/day 1
  • Particularly effective for patients with comorbid insomnia or depression
  • Side effects include dry mouth, sedation, and constipation

Other Evidence-Based Options

• Timolol: 20-30 mg/day 1
• Divalproex sodium/Sodium valproate: 500-1500 mg/day 1
  • Avoid in women of childbearing potential due to teratogenicity

Medication Selection Algorithm

1. Assess comorbidities:

   • Hypertension → Consider propranolol or timolol
   • Depression/anxiety → Consider amitriptyline
   • Obesity → Consider topiramate (associated with weight loss)
   • Epilepsy → Consider topiramate, divalproex sodium
   • Insomnia → Consider amitriptyline (evening dosing)

2. Evaluate contraindications:

   • Asthma/COPD → Avoid beta-blockers
   • Pregnancy/planning pregnancy → Avoid topiramate, valproate
   • Kidney stones → Use caution with topiramate
   • Bradycardia/heart block → Avoid beta-blockers

3. Start with lowest effective dose and titrate gradually:

   • For topiramate: Begin with 25 mg daily, increase by 25 mg weekly to target 100 mg/day 4
   • For propranolol: Start with lower doses and gradually increase to effective range

Non-Pharmacological Approaches

These should be implemented alongside medication therapy:

• Lifestyle modifications:

  • Regular sleep schedule
  • Consistent meal times
  • Adequate hydration
  • Regular physical exercise
  • Stress management techniques 1

• Complementary approaches with some evidence:

  • Magnesium supplements (400-600 mg daily)
  • Riboflavin supplements (400 mg daily)
  • Coenzyme Q10 supplements
  • Cognitive behavioral therapy
  • Relaxation techniques 1

Treatment Monitoring and Duration

• Evaluate response after 4-6 weeks of preventive treatment 1
• Continue effective prophylactic treatment for at least 3-6 months 1
• If discontinuing, taper gradually over several weeks to prevent rebound headaches
• Limit acute medications to prevent medication overuse headache:
  • NSAIDs ≤15 days/month
  • Triptans ≤10 days/month 1

Important Considerations and Pitfalls

• Medication overuse: Common in headache patients and can worsen symptoms; monitor acute medication use carefully 1
• Inadequate trial duration: Prophylactic medications require 2-3 months to demonstrate full efficacy; avoid premature discontinuation 4
• Insufficient dose: Underdosing is common; titrate to recommended therapeutic doses 3
• Abrupt discontinuation: Always taper preventive medications to avoid withdrawal symptoms or rebound headaches 1
• Monotherapy failure: Consider adjunctive therapy with a second agent from a different class if monotherapy provides partial but insufficient relief 6

Special Populations

• Breastfeeding women: For acute treatment, acetaminophen is preferred first-line, with ibuprofen and sumatriptan also considered safe options 1
• Chronic migraine with medication overuse: Topiramate has demonstrated efficacy even in the presence of medication overuse 5