What are the recommended treatments for migraine prevention?

Migraine Prevention: Evidence-Based Recommendations

When to Initiate Preventive Therapy

Preventive therapy should be started if you have ≥2 migraine attacks per month causing disability lasting ≥3 days, or if you're using acute medications more than twice weekly. 1, 2

Additional indications include:

• Contraindication to or failure of acute treatments 3, 1
• Presence of uncommon migraine variants (hemiplegic migraine, prolonged aura, migrainous infarction) 3, 1

First-Line Preventive Medications

Beta-blockers, topiramate, and candesartan represent the current first-line options based on the most recent guidelines. 1

Beta-Blockers

• Propranolol 80-240 mg/day is FDA-approved with the strongest evidence 1, 2
• Timolol 20-30 mg/day is also FDA-approved 3, 1
• Alternative beta-blockers include atenolol, bisoprolol, or metoprolol 1

Topiramate

• Target dose is 100 mg/day (typically 50 mg twice daily) 1
• This dose provides optimal efficacy without the increased side effects seen at 200 mg/day 4, 5
• Reduces migraine frequency by approximately 2 attacks per month 5, 6
• Particularly useful for patients concerned about weight gain or who are overweight, as it causes weight loss 4, 7
• Effective even in chronic migraine (≥15 headache days/month) and with medication overuse 6

Candesartan

• Recommended as first-line, especially for patients with comorbid hypertension 1, 2
• The VA/DoD guidelines strongly recommend candesartan or telmisartan for episodic migraine 2

Second-Line Preventive Medications

Amitriptyline

• Dose: 30-150 mg/day 3, 1
• Particularly effective for patients with mixed migraine and tension-type headache 1

Valproate/Divalproex

• Sodium valproate 800-1500 mg/day or divalproex sodium 500-1500 mg/day 3, 1
• Strictly contraindicated in women of childbearing potential due to teratogenic effects 1, 2

Flunarizine

• Effective second-line option where available 1

Third-Line: CGRP Monoclonal Antibodies

Consider erenumab, fremanezumab, galcanezumab, or eptinezumab when first- and second-line treatments have failed or are contraindicated. 1, 2

• The VA/DoD guidelines strongly recommend these for both episodic and chronic migraine 2
• Require 3-6 months to assess efficacy (longer than traditional preventives) 1

Implementation Strategy

Dosing Approach

Start with a low dose and titrate slowly upward in weekly increments until clinical benefit is achieved or side effects limit further increases. 3, 1, 2

For topiramate specifically:

• Increase by 25 mg weekly 6, 7, 8
• Target 100 mg/day for most patients 1, 4
• Allow dosing flexibility from 50-200 mg/day based on individual response 6

Trial Duration

Allow 2-3 months before determining efficacy for traditional preventives 3, 1, 2

• Topiramate may show benefit as early as the first month 7
• CGRP antibodies require 3-6 months for adequate assessment 1

Monitoring

Use daily headache diaries to track attack frequency, severity, duration, disability, treatment response, and adverse effects. 3, 2

Calculate percentage reduction in monthly migraine days to quantify success 1

Critical Pitfalls to Avoid

Medication Overuse Headache

Limit acute medication use to no more than twice weekly to prevent medication overuse headache, which interferes with preventive treatment efficacy. 3, 1, 2

Inadequate Trial Duration

Do not abandon a preventive medication before completing a full 2-3 month trial 3, 1

Starting Dose Too High

Rapid titration or high starting doses lead to poor tolerability and treatment discontinuation 1

Teratogenic Medications

Never prescribe valproate/divalproex to women of childbearing potential 1, 2

Duration and Discontinuation

After 6-12 months of successful therapy, consider tapering or discontinuing treatment to determine if it can be stopped. 3, 1

Non-Pharmacological Adjuncts

Consider as additions to medication or when medications are contraindicated:

• Neuromodulatory devices 1, 2
• Biobehavioral therapy 1, 2
• Acupuncture (though not superior to sham in controlled trials) 1
• Oral magnesium supplementation 2

Special Consideration: OnabotulinumtoxinA

For chronic migraine specifically, onabotulinumtoxinA is an option but carries significant risks including problems with swallowing, speaking, or breathing that can be life-threatening. 2, 9 Death can occur as a complication of severe swallowing or breathing problems. 9