Candesartan for Daily Headaches with Migrainous Features
Candesartan is recommended as a first-line medication for the prevention of daily headaches with migrainous features at a dose of 16 mg orally per day. 1, 2
Efficacy and Evidence
- Candesartan is recognized as a first-line preventive treatment for migraine in multiple clinical guidelines, alongside beta blockers and topiramate 1
- The standard therapeutic dose is 16 mg orally once daily, with the option to increase to 32 mg daily in patients requiring additional efficacy 2
- Clinical trials have demonstrated that candesartan significantly reduces the number of days with headache (18.5 vs 13.6 days over 12 weeks) and days with migraine (12.6 vs 9.0) compared to placebo 3
- Candesartan is particularly beneficial for patients who experience migraines on ≥2 days per month despite optimized acute treatment 1, 2
Treatment Protocol
- Begin with 16 mg oral candesartan once daily 2
- Maintain treatment for at least 2-3 months before determining efficacy 2
- If effective, continue treatment for 6-12 months before considering discontinuation 2
- For patients with inadequate response, dosage may be increased to 32 mg daily 2
Advantages of Candesartan
- Once-daily dosing improves treatment adherence 2
- Unlike beta blockers and tricyclic antidepressants, candesartan does not cause weight gain 1
- Unlike topiramate, candesartan does not cause cognitive slowing or depression 1
- Candesartan may provide dual benefits for patients with comorbid hypertension 4
Contraindications and Precautions
- Primary contraindication is co-administration with aliskiren 1, 2
- Candesartan is contraindicated during pregnancy due to potential fetal harm 1, 2
- Use with caution in patients with renal impairment 2
Monitoring and Evaluation
- Assess efficacy after 2-3 months of consistent use 2
- Success is measured by percentage reduction in monthly migraine days or headache intensity 2
- If ineffective after an adequate trial, consider switching to another first-line agent such as a beta blocker (propranolol, metoprolol) or topiramate 1, 2
Alternative Options
- If candesartan fails, consider second-line medications such as flunarizine, amitriptyline, or sodium valproate (the latter contraindicated in women of childbearing potential) 1
- Third-line options include CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) 1
- Non-pharmacological approaches like neuromodulatory devices, biobehavioral therapy, and acupuncture can be considered as adjuncts 1
Candesartan represents an excellent option for daily headaches with migrainous features due to its proven efficacy, favorable side effect profile, and convenient once-daily dosing schedule.