From the Guidelines
Migraine prophylaxis should be considered for patients experiencing frequent migraines (typically 2 or more monthly) or when migraines significantly impact quality of life despite acute treatments, with first-line medications including beta blockers, topiramate, or candesartan. The decision to start prophylaxis is based on the frequency and impact of migraines on daily life, with the goal of reducing the frequency and severity of attacks [ 1 ].
Key Considerations
- The most recent and highest quality study recommends considering preventive treatment in patients who are adversely affected by migraine on ≥2 days per month despite optimized acute treatment [ 1 ].
- First-line medications for migraine prophylaxis include beta blockers (such as atenolol, bisoprolol, metoprolol, or propranolol), topiramate, or candesartan [ 1 ].
- Second-line medications include flunarizine, amitriptyline, or (in men) sodium valproate [ 1 ].
- CGRP monoclonal antibodies are considered third-line medications [ 1 ].
- Non-pharmacological approaches like regular sleep patterns, stress management, exercise, and trigger avoidance should accompany medication.
Treatment Approach
When starting prophylaxis, begin with a low dose and gradually increase to minimize side effects. A prophylactic medication should be tried for at least 2-3 months at an adequate dose before determining effectiveness. If one medication fails, try another class. Prophylaxis works by modulating pain pathways, reducing cortical spreading depression, or inhibiting CGRP-mediated inflammation, ultimately decreasing the frequency and severity of migraine attacks.
Additional Options
Other effective options may include calcium channel blockers and newer CGRP monoclonal antibodies, but these should be considered based on the most recent guidelines and patient-specific factors [ 1 ].
Patient Education
Patient education on lifestyle modifications and the importance of adherence to prophylactic medication is crucial for effective management of migraines. Regular follow-up appointments should be scheduled to monitor the effectiveness of the treatment plan and make adjustments as necessary.
From the FDA Drug Label
Migraine: Propranolol hydrochloride extended-release capsules are indicated for the prophylaxis of common migraine headache The options for migraine prophylaxis include propranolol.
- Propranolol is indicated for the prophylaxis of common migraine headache 2
From the Research
Migraine Prophylaxis Options
The following are options for migraine prophylaxis:
- Beta blockers, such as propranolol, timolol, atenolol, metoprolol, and nadolol 3, 4, 5
- Antiepileptics, including topiramate, valproate, gabapentin, and lamotrigine 3, 4, 6, 7, 5
- Amitriptyline 3, 4, 5
- Non-steroidal anti-inflammatory drugs (NSAIDs), such as naproxen sodium 4, 5
- Botulinum toxin, although its role is still being defined 4, 5
- Other medications, including candesartan, lisinopril, fluoxetine, magnesium, vitamin B2 (riboflavin), coenzyme Q10, and hormone therapy, although evidence for these is limited 4, 5
- Alternative therapies, such as relaxation techniques, bio-feedback, cognitive behavioral therapy, and acupuncture, which may be effective but require more specialist time or technical devices 5
Considerations for Migraine Prophylaxis
When selecting a prophylactic treatment for migraine, considerations include: