From the Guidelines
Migraine prophylaxis should be initiated with first-line agents such as propranolol (80 to 240 mg/d), timolol (20 to 30 mg/d), amitriptyline (30 to 150 mg/d), divalproex sodium (500 to 1500 mg/d), and sodium valproate (800 to 1500 mg/d) to reduce the frequency, severity, and duration of migraine attacks. When selecting a prophylactic medication, it is essential to consider the patient's comorbidities, potential side effects, and previous treatment responses.
- The medications with proven efficacy for migraine prophylaxis include:
- Beta-blockers: propranolol and timolol
- Antidepressants: amitriptyline
- Antiepileptic drugs: divalproex sodium and sodium valproate
- Other medications, such as flunarizine, lisuride, pizotifen, time-released DHE, and methysergide, have shown efficacy but have limited published data on adverse events or frequent or severe adverse events 1. It is crucial to educate patients about the control of acute attacks and preventive therapy, engaging them in the formulation of a management plan, and reevaluating therapy on a regular basis 1. Patient input, through the use of daily flow sheets or diaries, can provide valuable information on attack frequency, severity, and duration, as well as response to treatment and adverse effects of medication, guiding treatment selection 1.
From the FDA Drug Label
Migraine: Propranolol hydrochloride extended-release capsules are indicated for the prophylaxis of common migraine headache The initial oral dose is 80 mg propranolol hydrochloride extended-release capsules once daily. The usual effective dose range is 160 to 240 mg once daily. The dosage may be increased gradually to achieve optimal migraine prophylaxis If a satisfactory response is not obtained within four to six weeks after reaching the maximal dose, propranolol hydrochloride extended-release capsules therapy should be discontinued.
Propranolol is used for migraine prophylaxis. The initial dose is 80 mg once daily, and the effective dose range is 160 to 240 mg once daily 2, 2.
- The dosage may be increased gradually to achieve optimal migraine prophylaxis.
- If a satisfactory response is not obtained within four to six weeks after reaching the maximal dose, propranolol hydrochloride extended-release capsules therapy should be discontinued.
From the Research
Migraine Prophylaxis Medicines
Migraine prophylaxis medicines are used to reduce the frequency, duration, or severity of migraine attacks. The choice of prophylactic treatment should be based on the efficacy and side-effect profile of the drug, as well as the patient's coexistent and comorbid conditions 3.
Medication Options
Some of the medication options for migraine prophylaxis include:
- β-blockers, such as propranolol, metoprolol, and timolol 4, 5
- Anticonvulsants, such as topiramate, valproate, and divalproex sodium 3, 4, 5
- Antidepressants, such as amitriptyline and selective serotonin-norepinephrine reuptake inhibitors (SNRIs) 3, 6
- Calcium channel antagonists, such as flunarizine 7, 6
- Neurotoxins, such as botulinum toxin A 4, 7, 6
- Nutraceuticals, such as riboflavin, feverfew, butterbur, and coenzyme Q10 7, 6, 5
Treatment Guidelines
The American Academy of Neurology (AAN) and the Canadian Headache Society (CHS) have published evidence-based guidelines for the preventive treatment of migraine 5. These guidelines recommend the use of certain medications, such as topiramate, propranolol, and divalproex sodium, for migraine prevention. The choice of preventive treatment should be based on the presence of comorbid and coexistent illness, patient preference, reproductive potential and planning, and best available evidence 5.
Principles of Preventive Treatment
Principles of preventive treatment are important to improve compliance, minimize side effects, and improve patient outcomes 5. This includes avoiding trigger factors, maintaining a regular lifestyle, and considering non-pharmacological treatments, such as relaxation techniques, bio-feedback, and cognitive behavioral therapy 7, 6.