From the Guidelines
For migraines not responding to flunarizine, the most effective alternative prophylactic option is to use CGRP monoclonal antibodies like erenumab, fremanezumab, or galcanezumab, as recommended by the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1.
Alternative Prophylaxis Options
Several alternative prophylactic options are available for migraines not responding to flunarizine. These include:
- Beta-blockers like propranolol or metoprolol, which are effective first-line alternatives, working by reducing vascular reactivity and neuronal excitability
- Anticonvulsants such as topiramate or valproate, which stabilize neuronal membranes and modulate neurotransmitter activity
- Antidepressants including amitriptyline or venlafaxine, which affect serotonin and norepinephrine pathways involved in pain modulation
- CGRP monoclonal antibodies like erenumab (70-140 mg monthly), fremanezumab (225 mg monthly), or galcanezumab (120 mg monthly), which offer a newer approach by targeting the calcitonin gene-related peptide pathway
Recommendation
The use of CGRP monoclonal antibodies is strongly recommended for the prevention of episodic or chronic migraine, as stated in the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1.
Additional Considerations
When switching medications, allow 2-3 months to properly evaluate effectiveness, and consider combining therapies from different classes for enhanced efficacy in difficult cases. Lifestyle modifications including regular sleep, stress management, and trigger avoidance should accompany any pharmacological approach.
Evidence-Based Decision
The recommendation to use CGRP monoclonal antibodies is based on the most recent and highest quality study available, which is the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1. This study provides strong evidence for the effectiveness of CGRP monoclonal antibodies in preventing episodic or chronic migraine.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Alternative Prophylaxis Options for Migraine
If a patient is not responding to Flunarizine, there are several alternative prophylaxis options available for migraine treatment. These options can be categorized into different classes of medications and non-pharmacological treatments.
Medication Options
- Beta-blockers: These are considered first-line treatment options for migraine prophylaxis 2, 3, 4.
- Topiramate: This anticonvulsant drug has been shown to be effective in reducing migraine frequency 2, 3, 5, 4.
- Valproic acid: This anticonvulsant drug is also considered a first-line treatment option for migraine prophylaxis 2, 3, 5, 4.
- Amitriptyline: This antidepressant is considered a first-line treatment option for migraine prophylaxis, especially in the US 2, 3, 4.
- Venlafaxine: This antidepressant is considered a second-line treatment option for migraine prophylaxis 2, 3.
- Gabapentin: This anticonvulsant drug is considered a second-line treatment option for migraine prophylaxis 2, 3, 5.
- Naproxen: This nonsteroidal anti-inflammatory drug (NSAID) is considered a second-line treatment option for migraine prophylaxis 2, 3.
- Butterbur root: This herbal remedy is considered a second-line treatment option for migraine prophylaxis 2, 3.
- Magnesium: This mineral is considered a second-line treatment option for migraine prophylaxis 2, 3.
Non-Pharmacological Options
- Relaxation techniques: These can be effective in reducing migraine frequency and severity 2.
- Bio-feedback: This technique can help patients become aware of and control their physiological responses to migraine triggers 2.
- Cognitive behavioral therapy: This type of therapy can help patients manage stress and other migraine triggers 2.
- Acupuncture: This traditional Chinese medicine technique involves inserting thin needles into specific points on the body to stimulate healing and reduce pain 2.