What are the recommended medications for migraine prophylaxis?

Recommended Medications for Migraine Prophylaxis

For migraine prophylaxis, first-line medications include beta blockers without intrinsic sympathomimetic activity (atenolol, bisoprolol, metoprolol, propranolol), topiramate, and candesartan, with CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) strongly recommended for cases where first-line treatments fail. 1

First-Line Prophylactic Medications

• Beta blockers: Propranolol, metoprolol, atenolol, and bisoprolol are effective first-line options for migraine prevention. These medications have strong evidence supporting their efficacy and should be considered among initial treatment choices. 1

• Topiramate: Recommended for both episodic and chronic migraine prevention with consistent evidence of efficacy. Typically started at low doses (25mg) and titrated up as needed. 1

• Candesartan: An angiotensin II receptor blocker that has demonstrated effectiveness as a first-line agent for migraine prophylaxis. 1

Second-Line Prophylactic Medications

• Amitriptyline: A tricyclic antidepressant with established efficacy for migraine prevention, particularly useful when migraine coexists with depression or tension-type headache. 1

• Flunarizine: A calcium channel blocker that has shown effectiveness as a second-line option for migraine prophylaxis. 1, 2

• Sodium valproate/Divalproex sodium: Effective for episodic migraine prevention but strictly contraindicated in women of childbearing potential due to teratogenic risk. 1

Third-Line Prophylactic Medications

• CGRP monoclonal antibodies: Erenumab, fremanezumab, and galcanezumab are strongly recommended for prevention of both episodic and chronic migraine, particularly when other preventive medications have failed. 1

• Intravenous eptinezumab: Another CGRP monoclonal antibody that has shown effectiveness for both episodic and chronic migraine prevention. 1

• OnabotulinumtoxinA: Recommended specifically for chronic migraine prevention (≥15 headache days per month) but not recommended for episodic migraine. 1

Additional Options with Supporting Evidence

• Lisinopril: An ACE inhibitor with evidence supporting its use for episodic migraine prevention. 1

• Oral magnesium: Has demonstrated efficacy in migraine prevention with minimal side effects. 1

• Memantine: An NMDA receptor antagonist that may be effective for episodic migraine prevention. 1

• Atogepant: A newer CGRP receptor antagonist recommended for episodic migraine prevention. 1

Medications Not Recommended or with Insufficient Evidence

• Gabapentin: Evidence does not support its use for episodic migraine prevention. 1

• Rimegepant: Currently has insufficient evidence to recommend for or against its use in episodic migraine prevention. 1

• Levetiracetam: Insufficient evidence to recommend for or against its use in migraine prevention. 1

Treatment Algorithm

1. Initiate prophylaxis when:

   • Patient experiences ≥2 migraine days per month with significant disability despite optimized acute treatment 1
   • Migraines significantly impact quality of life 1

2. First-line treatment:

   • Start with beta blockers (propranolol, metoprolol, atenolol, or bisoprolol), topiramate, or candesartan 1
   • Allow 2-3 months to assess efficacy of oral preventive medications 1

3. If first-line fails:

   • Switch to a different first-line agent or move to second-line options (flunarizine, amitriptyline, or sodium valproate [in men only]) 1

4. If second-line fails:

   • Consider CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) or onabotulinumtoxinA (for chronic migraine only) 1
   • Assess efficacy of CGRP monoclonal antibodies after 3-6 months 1
   • Assess efficacy of onabotulinumtoxinA after 6-9 months 1

Important Clinical Considerations

• Duration of treatment: Consider pausing preventive medication after 6-12 months of successful treatment to determine if it's still needed 1

• Medication overuse: Always assess and address medication overuse, as it can contribute to migraine chronification and reduce effectiveness of preventive treatments 1

• Dosing schedules: Simplified dosing schedules (once daily or less) can improve treatment adherence 1

• Special populations: In older patients, consider comorbidities and potential adverse effects when selecting prophylactic medications 1

• Non-pharmacological options: Consider neuromodulatory devices, biobehavioral therapy, and acupuncture as adjuncts to medication or as alternatives when medications are contraindicated 1