What are the recommendations for migraine prophylaxis management?

Management of Migraine Prophylaxis

First-line agents for migraine prophylaxis include propranolol (80-240 mg/day), timolol (20-30 mg/day), amitriptyline (30-150 mg/day), divalproex sodium (500-1500 mg/day), and sodium valproate (800-1500 mg/day). 1

Indications for Prophylactic Therapy

Prophylactic therapy should be considered in patients with:

• Two or more migraine attacks per month with disability lasting 3 or more days per month 1
• Contraindication to or failure of acute treatments 1
• Use of abortive medication more than twice per week 1, 2
• Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, or migrainous infarction) 1

First-Line Prophylactic Medications

Beta-Blockers

• Propranolol (80-240 mg/day) and timolol (20-30 mg/day) have good evidence for efficacy 1
• Common side effects include dizziness, nausea, fatigue, depression, and insomnia 1
• May be particularly appropriate for patients with comorbid hypertension 3

Antidepressants

• Amitriptyline (30-150 mg/day) shows good efficacy 1
• More effective in patients with mixed migraine and tension-type headache 1
• Side effects include weight gain, drowsiness, and anticholinergic symptoms 1
• Consider for patients with comorbid depression or anxiety 4

Anticonvulsants

• Divalproex sodium (500-1500 mg/day) and sodium valproate (800-1500 mg/day) have good evidence for efficacy 1
• May be particularly effective for patients with prolonged or atypical migraine aura 1
• Side effects include hair loss, tremor, weight gain, and teratogenic effects 1
• Topiramate is also effective based on more recent evidence 4, 5

Second-Line Prophylactic Medications

• Flunarizine (10 mg/day) - effective but may cause sedation, weight gain, depression, and extrapyramidal symptoms 1
• Methysergide - effective but limited data on adverse events 1
• Other agents with evidence of efficacy include:
  • Candesartan 4, 5
  • Venlafaxine 4
  • Gabapentin 4

Complementary and Alternative Therapies

• Butterbur, feverfew, magnesium citrate, riboflavin, and coenzyme Q10 have evidence supporting their use 4, 5
• These may be appropriate for patients seeking non-pharmaceutical options or those with contraindications to standard medications 5

Implementation of Prophylactic Therapy

• Start with a low dose and titrate slowly upward until clinical benefits are achieved or side effects limit further increases 1
• Allow adequate trial period of 2-3 months before determining efficacy 1
• Monitor for medication overuse, which can interfere with prophylactic treatment 1
• After a period of stability (6-12 months), consider tapering or discontinuing treatment 1

Special Considerations

• Avoid medications that may interfere with prophylactic treatment, such as overused acute medications like ergotamine 1
• For women with menstruation-related migraine, consider targeted prophylaxis around menstruation 1
• OnabotulinumtoxinA is FDA-approved for chronic migraine (≥15 headache days per month) but not for episodic migraine 6

Monitoring and Follow-up

• Use headache diaries to track attack frequency, severity, duration, resulting disability, response to treatment, and adverse effects 1
• Reassess efficacy after 2-3 months of treatment 1
• If treatment is ineffective, check for medication overuse or poor compliance 3
• Patient education about migraine as a disease and principles of management is essential for treatment success 1

Pitfalls to Avoid

• Failing to recognize medication overuse headache, which can occur with frequent use of acute medications (≥15 days per month with most medications; ≥10 days per month with triptans) 2
• Inadequate duration of prophylactic trial (less than 2-3 months) 1
• Starting at full dose rather than titrating gradually, which may lead to poor tolerability and discontinuation 1
• Not considering comorbid conditions when selecting prophylactic medication 3, 4