Can Flunarizine 10mg at bedtime provide effective migraine prophylaxis?

Flunarizine 10mg at Bedtime for Migraine Prophylaxis

Flunarizine 10mg taken at bedtime is an effective second-line medication for migraine prophylaxis, with proven efficacy comparable to propranolol, though it requires monitoring for side effects such as sedation, weight gain, depression, and extrapyramidal symptoms. 1, 2, 3

Efficacy and Place in Therapy

• Flunarizine is positioned as a second-line medication for migraine prophylaxis in current guidelines, after first-line options such as beta-blockers, topiramate, and candesartan 1, 3
• At 10mg daily, flunarizine reduces migraine attack frequency by approximately 0.4-0.55 attacks per 4 weeks compared to placebo 4, 5
• Flunarizine's effectiveness is comparable to propranolol 160mg daily, a commonly used first-line prophylactic agent 5, 6
• Clinical response rates show approximately 53% of patients achieve at least a 50% reduction in attack frequency with flunarizine 10mg 6

Dosing and Administration

• The standard recommended dose is 10mg once daily, typically administered at bedtime to minimize daytime sedation 2, 3
• A lower dose of 5mg daily may also be effective for some patients, though with potentially slightly lower response rates 6
• Clinical benefits may take 2-3 months to fully manifest, so an adequate trial period of at least 3-4 months is necessary before determining efficacy 2, 7
• After a period of stability (typically 6-12 months), consider tapering or discontinuing treatment to assess continued need 1, 3

Side Effects and Monitoring

• Common adverse events include:
  • Sedation/somnolence (reported in up to 20.5% of patients) 2, 4
  • Weight gain 2, 3, 8
  • Abdominal pain 2, 3
• More serious concerns include:
  • Depression, particularly in elderly patients 2, 3
  • Extrapyramidal symptoms, more commonly observed in elderly persons 2, 3
• Regular follow-up is recommended at 2-3 months after initiation and then every 6-12 months to assess efficacy and monitor for side effects 1

Clinical Decision Algorithm

1. Confirm migraine diagnosis and need for prophylaxis:

   • Consider prophylaxis for patients with ≥2 migraine attacks per month with significant disability 1, 3
   • Evaluate attack frequency, severity, and migraine-related disability using headache calendars 1

2. Try first-line agents before considering flunarizine:

   • First-line options include beta-blockers (propranolol), topiramate, and candesartan 1, 3

3. Consider flunarizine as a second-line option when:

   • First-line agents have failed or are contraindicated 2, 3
   • Patient has no history of depression or parkinsonism 1, 2
   • Use caution in elderly patients due to increased risk of extrapyramidal symptoms 2, 3

4. Initiate and monitor treatment:

   • Start with 10mg at bedtime 1, 2
   • Evaluate response after 2-3 months of treatment 1, 2
   • Monitor for common side effects at follow-up visits 1, 2

Clinical Pearls and Pitfalls

• Flunarizine requires an adequate trial period of at least 3 months to properly assess efficacy 2, 7
• Avoid flunarizine in patients with significant depression or those at high risk for developing depression 2, 3
• Monitoring for extrapyramidal symptoms is particularly important in elderly patients 2, 3
• In real-world clinical practice, many patients (64% in one UK study) continue treatment for more than 1 year when effective 8
• Consider using headache calendars to objectively assess response to treatment 1