What are the medications used for migraine prevention?

Migraine Prevention Medications

Beta-blockers (propranolol, timolol), antidepressants (amitriptyline), and anticonvulsants (topiramate, divalproex sodium) are the first-line medications for migraine prevention, with specific dosage recommendations established by the American Academy of Neurology. 1

First-Line Preventive Medications

Beta-Blockers

• Propranolol: 80-240 mg/day 1, 2

  • Proven efficacy in migraine prevention in FDA-approved studies 2
  • Contraindicated in patients with asthma, heart failure, Raynaud's disease, atrioventricular block, or depression 1
  • Requires monitoring for cardiovascular effects

• Timolol: 20-30 mg/day 1

  • Effective alternative beta-blocker option

Anticonvulsants

• Topiramate: 100 mg/day 1, 3

  • Demonstrated significant reduction in monthly migraine frequency compared to placebo 3
  • Side effects include paresthesia, fatigue, cognitive issues, and metabolic acidosis 4
  • Extended-release formulations may offer better tolerability with once-daily dosing 4

• Divalproex sodium/Sodium valproate: 500-1500 mg/day 1

  • IMPORTANT: Contraindicated during pregnancy due to teratogenicity 1, 5
  • May have more adverse effects compared to topiramate 5

Antidepressants

• Amitriptyline: 30-150 mg/day 1
  • Recommended by the American Headache Society for migraine prevention 1
  • Consider for patients with comorbid depression or sleep disturbances

Second-Line Preventive Medications

• Other beta-blockers: Atenolol, nadolol 6

  • Consider when first-line beta-blockers are not tolerated

• Venlafaxine 6

  • Alternative antidepressant option when amitriptyline is not tolerated

Limited Evidence Medications

The following medications have limited evidence but may be considered in specific cases:

• Calcium channel blockers: Verapamil, nimodipine, nifedipine, nicardipine 1, 6
• ACE inhibitors: Lisinopril 6
• ARBs: Candesartan 6
• Other anticonvulsants: Gabapentin 6

Complementary Treatments

These treatments have evidence supporting their use in migraine prevention:

• Petasites (butterbur)
• Feverfew
• Magnesium
• Riboflavin (vitamin B2) 6

Clinical Considerations

When to Consider Preventive Therapy

Preventive therapy should be initiated when patients experience:

• Four or more headaches per month
• Eight or more headache days per month
• Debilitating headaches
• Medication-overuse headaches 6

Monitoring and Management

• Start with low doses and titrate slowly to minimize adverse effects
• Evaluate effectiveness after 2-3 months of therapy at target dose
• Monitor for medication-specific adverse effects
• For topiramate: watch for cognitive effects, paresthesia, and metabolic acidosis 4
• For propranolol: monitor heart rate, blood pressure, and potential drug interactions 2
• For valproate: liver function tests and pregnancy testing in women of childbearing potential 1

Common Pitfalls to Avoid

1. Using valproate in women of childbearing potential without adequate contraception
2. Failing to start at low doses and titrate slowly
3. Discontinuing therapy too early before reaching therapeutic effect (typically 2-3 months)
4. Not addressing medication overuse headaches before starting preventive therapy
5. Using opioids for chronic headache management 1

By following these evidence-based recommendations for migraine prevention medications, clinicians can effectively reduce migraine frequency, severity, and associated disability while minimizing adverse effects.