Preventative Medications for Migraine Treatment
The first-line preventative medications for migraine include beta-blockers (propranolol, metoprolol, timolol), anticonvulsants (topiramate, divalproex sodium, sodium valproate), and candesartan, which have strong evidence supporting their efficacy in reducing migraine frequency and severity. 1, 2, 3
First-Line Preventative Medications
- Beta-blockers are recommended as first-line agents, with propranolol having FDA approval for migraine prevention at doses of 120-160mg daily 4
- Topiramate is effective for migraine prevention and should be offered to patients to reduce attack frequency and severity 3
- Divalproex sodium and sodium valproate have strong evidence supporting their use in migraine prevention 3
- Candesartan has sufficient evidence to be considered a first-line preventative treatment 1, 2
Second-Line Preventative Medications
- Flunarizine (calcium channel blocker) is recommended as a second-line treatment after beta-blockers, topiramate, and candesartan, with a recommended dose of 10mg/day 5
- Amitriptyline (tricyclic antidepressant) has evidence supporting its use, particularly when combined with cognitive behavioral therapy 6
- Gabapentin has fair evidence of effectiveness for migraine prevention 7
Nutraceuticals with Evidence for Prevention
- Petasites (butterbur) has received strong recommendations for use based on evidence and expert consensus 2
- Riboflavin (vitamin B2), coenzyme Q10, and magnesium citrate have sufficient evidence to support their use in migraine prevention 1, 2
Special Considerations
- When prescribing topiramate or valproate to women of childbearing potential, discuss teratogenic effects and advise patients to use effective birth control methods and take folate 6
- Flunarizine's most common adverse effects include sedation, weight gain, and abdominal pain, with clinical benefits taking 2-3 months to manifest 5
- Propranolol's efficacy in migraine prevention has been demonstrated in placebo-controlled studies, with doses ranging from 40-160mg daily 4, 8
Treatment Algorithm
- Consider preventive treatments in patients with frequent or disabling headaches or medication overuse 6
- Start with first-line agents (beta-blockers, topiramate, divalproex sodium, or candesartan) based on comorbidities and potential side effects 1, 2
- If first-line treatments are ineffective or poorly tolerated, move to second-line options such as flunarizine or amitriptyline 5
- Allow adequate trial periods (2-3 months) before determining efficacy of preventive medications 5
- Discuss with patients that placebo was as effective as studied medications in many trials, particularly in children and adolescents 6
Common Pitfalls and Caveats
- Preventive migraine treatments are often underutilized in clinical practice despite strong evidence supporting their efficacy 2
- Lamotrigine has been proven ineffective for migraine prevention and should not be used for this purpose 3
- Combination therapy (e.g., propranolol and nortriptyline) may be considered when monotherapy is ineffective, though more studies are needed 8
- Head-to-head studies comparing topiramate and divalproex sodium suggest similar efficacy (approximately 50-58% of patients experiencing >50% reduction in headache frequency) 9