What are the preventive treatment options for migraines without aura?

Preventive Treatment Options for Migraines Without Aura

First-line preventive medications for migraine without aura include beta blockers (atenolol, bisoprolol, metoprolol, propranolol), candesartan, and topiramate based on the strongest evidence for efficacy and safety. 1, 2

Indications for Preventive Therapy

• Preventive treatment should be considered when patients experience:
  • Two or more migraine attacks per month with disability lasting 3 or more days 1, 2
  • Use of acute rescue medications more than twice per week 1, 2
  • Failure of or contraindications to acute treatments 1
  • Presence of uncommon migraine conditions (e.g., hemiplegic migraine) 1

First-Line Preventive Medications

Beta Blockers

• Propranolol (80-240 mg/day) - FDA approved for migraine prophylaxis 3
• Metoprolol (50-100 mg twice daily or 200 mg modified-release once daily) 1
• Atenolol (25-100 mg twice daily) 1
• Bisoprolol (5-10 mg once daily) 1
• Timolol (20-30 mg/day) 1
• Contraindications: asthma, cardiac failure, Raynaud disease, atrioventricular block, depression 1

Angiotensin II Receptor Blockers

• Candesartan (16-32 mg daily) 1, 2
• Contraindication: co-administration of aliskiren 1

Anticonvulsants

• Topiramate (50-100 mg daily) 1, 4
• Start at low dose (25 mg) and titrate slowly (25 mg/week) to improve tolerability 4, 5
• About 25% of patients respond to lower doses (50 mg/day), while approximately 50% require 100 mg/day 4
• Contraindications: nephrolithiasis, pregnancy, lactation, glaucoma 1

Second-Line Preventive Medications

• Amitriptyline (10-100 mg at night) 1

  • More effective for patients with mixed migraine and tension-type headache 1
  • Contraindications: age <6 years, heart failure, co-administration with MAOIs and SSRIs, glaucoma 1

• Flunarizine (5-10 mg once daily) 1

  • Contraindications: parkinsonism, depression 1

• Sodium valproate (600-1,500 mg once daily) 1

  • May be particularly effective for prolonged or atypical migraine aura 1
  • Absolutely contraindicated in women of childbearing potential 1
  • Other contraindications: liver disease, thrombocytopenia 1

Third-Line Preventive Medications

• CGRP monoclonal antibodies 1:

  • Erenumab (70 or 140 mg subcutaneous once monthly)
  • Fremanezumab (225 mg subcutaneous once monthly or 675 mg quarterly)
  • Eptinezumab (100 or 300 mg intravenous quarterly)

• OnabotulinumtoxinA (155-195 units to 31-39 sites every 12 weeks) 1

  • Contraindication: infection at injection site 1

Special Considerations

For Menstrual Migraine

• For pure menstrual migraine without aura, consider perimenstrual preventive treatment 1:
  • Long-acting NSAID (e.g., naproxen) for 5 days, starting 2 days before expected menstruation 1
  • Long-acting triptan (e.g., frovatriptan or naratriptan) following the same schedule 1
  • Some women with pure menstrual migraine without aura may benefit from continuous use of combined hormonal contraceptives 1

For Children and Adolescents

• Consider propranolol, amitriptyline, or topiramate for prevention 1

Implementation of Preventive Therapy

• Start with a low dose and increase slowly until benefits are achieved or limited by side effects 1, 2
• Allow an adequate trial period of 2-3 months before determining efficacy 1, 2
• Monitor for effectiveness using headache calendars to track:
  • Attack frequency (headache/migraine days per month)
  • Attack severity
  • Migraine-related disability 1

Common Pitfalls to Avoid

• Medication overuse headache: Limit use of acute treatments to no more than twice weekly 1, 2
• Inadequate trial duration: Benefits may not appear for 2-3 months after starting preventive therapy 1
• Abrupt discontinuation: After a period of stability (6-12 months), consider gradually tapering rather than abruptly stopping preventive medication 1
• Ignoring comorbidities: Consider patient's other medical conditions when selecting preventive therapy 6

Non-Pharmacological Options

• Consider as adjuncts to medication or when medications are contraindicated 1:
  • Neuromodulatory devices 1
  • Biobehavioral therapy 1
  • Acupuncture 1
  • Supplements with evidence of efficacy: petasites, feverfew, magnesium, riboflavin 7, 2