What is the typical dosing of candesartan (angiotensin II receptor antagonist) for migraine prophylaxis?

Candesartan Dosing for Migraine Prophylaxis

For migraine prophylaxis, candesartan should be dosed at 16-32 mg orally per day. 1

Dosing Guidelines

• Candesartan is recommended as a first-line medication for the prevention of episodic migraine with strong evidence supporting its efficacy 1
• The standard therapeutic dose is 16 mg orally per day as used in clinical trials 1, 2
• Dosing may be increased up to 32 mg orally per day in some patients who need additional efficacy 1
• Treatment should be maintained for at least 2-3 months before determining efficacy 1

Efficacy and Evidence

• Candesartan has demonstrated efficacy comparable to propranolol (a traditional first-line agent) in head-to-head trials 3
• In placebo-controlled studies, candesartan 16 mg daily reduced migraine days per month from 18.5 to 13.6 (p=0.001) 2
• Response rates (>50% reduction in migraine days) of approximately 31-43% have been reported with candesartan 3, 2
• Candesartan's efficacy has been confirmed in multiple randomized controlled trials, supporting its position as a first-line agent 4, 5

Practical Considerations

• Candesartan should be considered for preventive treatment in patients experiencing migraines on ≥2 days per month despite optimized acute treatment 1
• Treatment adherence is improved with once-daily dosing, making candesartan an attractive option 1
• For most preventive medications including candesartan, treatment should be continued for 6-12 months if successful before considering discontinuation 1
• Candesartan offers particular advantages for patients with comorbid hypertension 6, 4

Contraindications and Precautions

• Primary contraindication is co-administration of aliskiren 1
• Candesartan is contraindicated during pregnancy due to potential fetal harm 1
• Caution should be used in patients with renal impairment 4
• Unlike triptans, candesartan can often be used in patients with cardiovascular disease, making it valuable for patients with both conditions 6

Treatment Evaluation

• Efficacy should be assessed after 2-3 months of consistent use 1
• Success is measured by percentage reduction in monthly migraine days or monthly headache days of moderate-to-severe intensity 1
• If ineffective after an adequate trial of 2-3 months, consider switching to another first-line agent (beta-blocker or topiramate) or moving to second-line options 1