What are the recommended prophylactic medications for migraines?

Recommended Prophylactic Medications for Migraines

The most effective first-line prophylactic medications for migraine prevention are propranolol (80-240 mg/day), timolol (20-30 mg/day), topiramate (100 mg/day), amitriptyline (30-150 mg/day), and candesartan, with propranolol having the strongest evidence base. 1

Indications for Preventive Therapy

• Preventive therapy should be considered for patients experiencing two or more migraine attacks per month with disability lasting 3 or more days per month 1
• Patients using acute medications more than twice weekly should receive preventive therapy to avoid medication overuse headache 1
• Those with contraindications to or failure of acute treatments are candidates for preventive therapy 1
• Patients with uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, migrainous infarction) should receive preventive treatment 1

First-Line Prophylactic Medications

Beta-Blockers

• Propranolol (80-240 mg/day) has FDA approval for migraine prophylaxis with strong evidence for efficacy 1, 2
• The usual effective dose range for propranolol is 160-240 mg once daily for migraine prophylaxis 2
• Timolol (20-30 mg/day) is another effective beta-blocker option 1
• Beta-blockers are particularly useful in patients with comorbid hypertension or anxiety 1

Anticonvulsants

• Topiramate (100 mg/day) has demonstrated significant efficacy in multiple randomized controlled trials 3, 4
• The recommended target dose is 100 mg/day (typically 50 mg twice daily), as higher doses (200 mg/day) show no additional benefit but cause more side effects 3, 5
• Topiramate is particularly beneficial for patients concerned about weight gain, as it typically causes weight loss 3
• Divalproex sodium (500-1500 mg/day) and sodium valproate (800-1500 mg/day) are effective but strictly contraindicated in women of childbearing potential due to teratogenic effects 1

Other Options

• Amitriptyline (30-150 mg/day) is particularly effective in patients with mixed migraine and tension-type headache 1
• Candesartan is recommended as a first-line agent, especially for patients with comorbid hypertension 1

Implementation of Preventive Therapy

• Start with a low dose and titrate slowly to minimize side effects 1
  • For propranolol, start with 80 mg once daily and increase gradually 2
  • For topiramate, begin with 25 mg and increase by 25 mg weekly to target dose of 100 mg/day 6
• Allow an adequate trial period of 2-3 months before determining efficacy 1, 6
• If satisfactory response is not achieved after reaching the maximum dose, consider discontinuing gradually over several weeks 2
• Monitor for medication overuse, which can interfere with preventive treatment 1

Common Pitfalls to Avoid

• Failing to recognize medication overuse headache from frequent use of acute medications 1
• Starting with too high a dose, leading to poor tolerability and discontinuation 1
• Inadequate duration of preventive trial (less than 2-3 months) 1
• Not addressing comorbidities that may influence treatment selection 1
• Not considering contraindications (e.g., avoiding valproate in women of childbearing potential, beta-blockers in patients with asthma) 1

Monitoring and Follow-up

• Track progress with a headache diary to assess attack frequency, severity, duration, disability, treatment response, and adverse effects 1
• Consider tapering or discontinuing treatment after a period of stability 7
• For propranolol, if discontinuing, reduce dosage gradually over a period of a few weeks to avoid potential withdrawal effects 2

By following these evidence-based guidelines for prophylactic migraine treatment, clinicians can significantly reduce the frequency and severity of migraine attacks, improving patients' quality of life and reducing disability.