What is the recommended dose of pregabalin (lyrica) for treating migraine headaches?

Pregabalin Dosing for Migraine Headaches

Pregabalin is not recommended for migraine treatment as it lacks FDA approval and sufficient evidence for this indication. First-line preventive treatments for migraine include beta-blockers, antidepressants, and anticonvulsants like topiramate and valproate. 1, 2

Standard Migraine Treatment Approaches

• First-line acute treatments for migraines include NSAIDs (aspirin, ibuprofen, naproxen sodium) and triptans (sumatriptan, rizatriptan, zolmitriptan) 3, 2
• First-line preventive medications include propranolol (80-240 mg/day), timolol (20-30 mg/day), amitriptyline (30-150 mg/day), divalproex sodium (500-1500 mg/day), and sodium valproate (800-1500 mg/day) 3
• Preventive treatment should be considered for patients experiencing ≥2 migraine days per month with significant disability 2

Evidence on Pregabalin for Migraine

• Current migraine treatment guidelines do not include pregabalin among recommended first-line or second-line treatments for either acute migraine attacks or migraine prevention 1, 2
• A Cochrane review found no published evidence from controlled trials of pregabalin for the prophylaxis of episodic migraine in adults 4
• One small open-label study suggested that pregabalin starting at 75 mg/day and titrated to 300 mg/day might reduce migraine frequency, but this had significant limitations including small sample size and uncontrolled design 5
• A randomized double-blinded study comparing pregabalin (50 mg twice daily) with sodium valproate (200 mg twice daily) found comparable efficacy, though pregabalin was not significantly effective in reducing attack frequency during the first month of therapy 6

Pregabalin Dosing Information (For Off-Label Use)

• If pregabalin is considered for off-label use in migraine prophylaxis after failure of standard treatments, the dosing protocol used in limited research includes:
  • Starting dose: 50 mg twice daily or 75 mg/day 3, 6
  • Titration: Increase to 300 mg/day after 3-7 days, then by 150 mg/day every 3-7 days as tolerated 3
  • Maximum dosage: 600 mg/day (200 mg three times daily) or 300 mg twice daily 3
  • Duration of adequate trial: 4 weeks 3

Important Considerations and Cautions

• Pregabalin requires dosage reduction in patients with renal impairment 3
• Common adverse effects include dose-dependent dizziness and sedation, which can be reduced by starting with lower dosages and titrating cautiously 3
• Pregabalin is a Schedule V controlled substance due to potential for abuse and dependence 7
• Pregabalin has linear pharmacokinetics, making dosing more straightforward than gabapentin 3

Clinical Recommendation

• For migraine treatment, established first-line options should be used before considering pregabalin 1, 2
• If standard preventive treatments fail, a trial of pregabalin could be considered, starting at 50-75 mg/day and titrating to 300 mg/day over several weeks 3, 6
• Monitor for efficacy over at least 4 weeks at the target dose 3
• Discontinue if no significant benefit is observed after an adequate trial period 3