What are the recommended preventative medications for headaches?

Recommended Preventative Medications for Headaches

Beta-blockers (propranolol), antidepressants (amitriptyline), and anticonvulsants (topiramate, divalproex sodium) are the first-line preventative medications for headaches, with specific dosing recommendations based on the American Academy of Neurology guidelines. 1

First-Line Preventative Medications

Beta-Blockers

• Propranolol: 80-240 mg/day 1
• Timolol: 20-30 mg/day 1
• Caution: Avoid in patients with asthma, heart failure, Raynaud's disease, atrioventricular block, or depression 1
• Drug interactions: Propranolol has multiple interactions with CYP450 enzymes and can interact with migraine drugs like zolmitriptan and rizatriptan, increasing their concentrations 2

Antidepressants

• Amitriptyline: 30-150 mg/day 1
• Start at lower doses and titrate up to minimize side effects

Anticonvulsants

• Divalproex sodium: 500-1500 mg/day 1
• Sodium valproate: 800-1500 mg/day 1
• Topiramate: 100 mg/day 1
  • Titrate slowly: Start at 25 mg daily and increase by 25 mg weekly to target dose 3
  • Consider twice-daily dosing of immediate-release formulation for better tolerability 4
  • Extended-release formulations may offer better cognitive side effect profiles 4
• Important warning: Valproate is contraindicated during pregnancy due to teratogenicity 1, 5

Non-Pharmacological Preventative Approaches

The American Academy of Family Physicians recommends several evidence-based non-pharmacological approaches:

• Relaxation training
• Thermal biofeedback combined with relaxation training
• Electromyographic biofeedback
• Cognitive-behavioral therapy 1

Complementary Approaches

• Magnesium supplements
• Riboflavin supplements
• Coenzyme Q10 supplements 1

Medication Management Considerations

Avoiding Medication Overuse

• Limit NSAIDs to ≤15 days/month
• Limit triptans to ≤10 days/month 1
• Medication overuse can worsen headache symptoms and lead to chronic daily headache 1

Special Populations

• Pregnancy: Acetaminophen is the first-line treatment for acute attacks (650-1000 mg every 4-6 hours, maximum 4g/day) 1
• Chronic migraine: Topiramate has shown efficacy in randomized controlled trials, even in the presence of medication overuse 3

Common Pitfalls and Caveats

1. Inadequate trial duration: Preventative medications should be continued for 2-3 months before evaluating efficacy, although some patients may show response earlier 6

2. Insufficient dose titration: Start low and gradually increase to minimize side effects while reaching therapeutic doses

3. Ignoring contraindications:

   • Valproate in pregnancy 1, 5
   • Beta-blockers in patients with asthma, heart failure, or certain cardiac conditions 1

4. Overlooking side effect management:

   • For topiramate: Paresthesia is common but rarely causes discontinuation; cognitive problems are less common but more troublesome 4
   • Maintain hydration to reduce risk of kidney stones with topiramate 4

5. Failing to address lifestyle factors: Regular sleep schedule, consistent meal times, adequate hydration, regular exercise, and stress management techniques can help prevent headache attacks 1

6. Opioid use: Avoid opioids for chronic daily headaches due to risk of dependency, rebound headaches, and loss of efficacy 1

By following these evidence-based recommendations for preventative headache medications, clinicians can effectively reduce headache frequency and improve quality of life for patients suffering from recurrent headaches.