What medication is recommended for migraine prevention?

Migraine Prevention Medication Recommendations

For migraine prevention, candesartan, telmisartan, erenumab, fremanezumab, or galcanezumab are strongly recommended as first-line treatments based on the most recent evidence. 1

First-Line Preventive Medications

• Candesartan or telmisartan are strongly recommended for prevention of episodic migraine 1
• CGRP monoclonal antibodies including erenumab, fremanezumab, or galcanezumab are strongly recommended for prevention of both episodic and chronic migraine 1
• Propranolol (80-240 mg/day) is recommended with a weak recommendation but has established efficacy 1, 2
• Topiramate (100 mg/day, typically 50 mg twice daily) is suggested with a weak recommendation for prevention of both episodic and chronic migraine 1, 2

Second-Line Preventive Medications

• Intravenous eptinezumab is suggested for prevention of episodic or chronic migraine 1
• Lisinopril is suggested for prevention of episodic migraine 1
• Oral magnesium is suggested for migraine prevention 1
• Valproate is suggested for prevention of episodic migraine, but is strictly contraindicated in women of childbearing potential due to teratogenic effects 1, 2
• Memantine is suggested for prevention of episodic migraine 1
• Atogepant is suggested for prevention of episodic migraine 1
• OnabotulinumtoxinA injection is suggested specifically for prevention of chronic migraine (but not recommended for episodic migraine) 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 2
• Patients using abortive medication more than twice per week should be considered for preventive treatment to avoid medication overuse headache 2
• Patients with contraindications to or failure of acute treatments should be evaluated for preventive therapy 2

Implementation of Preventive Therapy

• Start with a low dose and titrate slowly until clinical benefits are achieved or side effects limit further increases 2
• Allow an adequate trial period of 2-3 months before determining efficacy 2
• For CGRP monoclonal antibodies, efficacy should be assessed only after 3-6 months of treatment 2
• Monitor for medication overuse, which can interfere with preventive treatment 2
• Use headache diaries to track attack frequency, severity, duration, disability, treatment response, and adverse effects 2

Medications to Avoid

• Gabapentin is not recommended for prevention of episodic migraine 1
• AbobotulinumtoxinA or onabotulinumtoxinA injections are not recommended for prevention of episodic migraine 1
• Galcanezumab is not recommended for prevention of chronic cluster headache 1

Common Pitfalls and Considerations

• Failing to recognize medication overuse headache from frequent use of acute medications can interfere with preventive treatment efficacy 2
• Starting with too high a dose can lead to poor tolerability and treatment discontinuation 2
• Inadequate duration of preventive trial (less than 2-3 months) may lead to premature discontinuation of potentially effective treatments 2
• Address comorbidities that may influence treatment selection (e.g., avoiding valproate in women of childbearing potential) 2
• Consider tapering or discontinuing treatment after 6-12 months of successful therapy to determine if it can be discontinued 2

By following these evidence-based recommendations, clinicians can select appropriate preventive medications for patients with migraine, improving outcomes and quality of life while minimizing adverse effects.