What are the recommended treatments for migraine prevention?

Recommended Treatments for Migraine Prevention

First-line pharmacologic treatments for migraine prevention include propranolol, timolol, amitriptyline, divalproex sodium, and topiramate, based on their established efficacy and safety profiles. 1

Initial Approach to Migraine Prevention

Before initiating pharmacologic treatment, consider these foundational steps:

• Identify and address modifiable triggers and lifestyle factors including maintaining regular sleep patterns, adequate hydration, regular physical activity, and stress management 1
• Ensure patient is using appropriate acute treatments for migraine attacks 1
• Consider preventive therapy for patients experiencing:
  • Two or more migraine attacks per month with disability lasting 3+ days per month 1
  • Use of acute medications more than twice weekly 1
  • Severe debilitating headaches despite adequate acute treatment 1
  • Contraindications to or failure of acute treatments 1
  • Uncommon migraine conditions (e.g., hemiplegic migraine, prolonged aura) 1

First-Line Pharmacologic Treatments

Based on the most recent evidence, first-line medications include:

• Beta-blockers:

  • Propranolol (80-240 mg/day) 1
  • Timolol (20-30 mg/day) 1
  • Common side effects include dizziness, fatigue, and insomnia, but are generally well-tolerated 1

• Tricyclic antidepressants:

  • Amitriptyline (30-150 mg/day) 1
  • Particularly useful when migraine coexists with tension-type headache, depression, or sleep disorders 2

• Anticonvulsants:

  • Divalproex sodium (500-1,500 mg/day) 1
  • Topiramate (dose should be started low and gradually increased) 1, 2
  • Topiramate may lead to weight loss but can have cognitive side effects 2

Second-Line Treatments

If first-line treatments are ineffective or not tolerated, consider:

• ACE inhibitors (lisinopril) 1
• ARBs (candesartan or telmisartan) 1, 3
• SSRIs (fluoxetine) 1
• Venlafaxine 4
• Atenolol and nadolol 4

Complementary and Alternative Treatments

Evidence supports the use of these nutraceuticals:

• Petasites (butterbur) 4, 2
• Feverfew 4, 2
• Magnesium citrate 4, 2, 3
• Riboflavin (vitamin B2) 4, 2, 3
• Coenzyme Q10 2, 3

These options have fewer side effects but generally lower efficacy than pharmacologic treatments 2.

Non-Pharmacologic Approaches

Several behavioral interventions have demonstrated effectiveness:

• Cognitive behavioral therapy 1, 3
• Relaxation training 1, 3
• Biofeedback combined with relaxation training 4, 3
• Mindfulness-based treatments 1

Special Considerations

Treatment Implementation

• Start medications at a low dose and gradually increase until desired outcomes are achieved 1
• Allow adequate trial period (generally 2-3 months) before determining efficacy 1
• Use a headache diary to track frequency, severity, and response to treatment 1
• Consider cost when selecting treatments, as many have similar efficacy profiles 1

Women of Childbearing Potential

• Discuss potential teratogenic effects, particularly with topiramate and valproate 1
• Advise on effective contraception and folate supplementation if these medications are used 1
• Magnesium may be particularly useful during pregnancy 2

Treatment for Chronic Migraine

• OnabotulinumtoxinA (Botox) is FDA-approved for chronic migraine (15+ headache days/month) 5, 3

Common Pitfalls to Avoid

• Failing to address medication overuse, which can lead to rebound headaches 1
• Discontinuing treatment too early before therapeutic effect is achieved 1
• Not starting at low doses and gradually titrating up, leading to unnecessary side effects 1
• Overlooking the importance of lifestyle modifications and trigger avoidance 1
• Not using a headache diary to objectively assess treatment efficacy 1

Treatment Algorithm

1. Begin with lifestyle modifications and trigger identification
2. If headaches remain frequent or disabling, select a first-line agent based on:
   • Comorbid conditions (e.g., beta-blockers for patients with hypertension)
   • Potential side effect profile (e.g., avoid topiramate if cognitive issues are a concern)
   • Patient preferences and medication costs
3. Start at a low dose and gradually increase over 2-4 weeks
4. Evaluate efficacy after 2-3 months of treatment at an adequate dose
5. If inadequate response, try another first-line agent or consider combination therapy
6. If first-line agents fail, move to second-line options or consider complementary treatments
7. For patients with chronic migraine, consider onabotulinumtoxinA