What are the recommended treatments for migraine prevention?

Migraine Prevention: Recommended Treatments

For adults with frequent migraines (≥2 attacks per month with significant disability), initiate preventive therapy with propranolol (80-240 mg/day), topiramate (100 mg/day), or candesartan as first-line agents, choosing based on cost and comorbidities. 1, 2

When to Start Preventive Therapy

Preventive treatment is indicated for patients who meet any of these criteria:

• ≥2 migraine attacks per month with disability lasting ≥3 days per month 1
• Using acute medications more than twice weekly (risk of medication overuse headache) 1, 2
• Severe debilitating headaches despite adequate acute treatment 2
• Contraindications to or failure of acute treatments 1
• Uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction) 1

First-Line Pharmacologic Options

Beta-Blockers

• Propranolol (80-240 mg/day) and timolol (20-30 mg/day) have the strongest evidence for efficacy and are FDA-approved 1, 3
• Particularly advantageous for patients with comorbid hypertension or anxiety 2
• Alternative beta-blockers include atenolol, bisoprolol, or metoprolol 1

Topiramate

• Recommended dose: 100 mg/day (typically 50 mg twice daily) 1
• Strictly contraindicated in women of childbearing potential due to teratogenic effects unless using effective contraception and folate supplementation 1, 2
• May cause weight loss but carries risk of cognitive adverse effects 1

Candesartan

• Effective first-line agent, especially useful for patients with comorbid hypertension 1

Second-Line Options

If first-line treatments fail after 2-3 months or cause intolerable side effects:

• Amitriptyline (30-150 mg/day): Particularly useful for patients with comorbid depression, anxiety, sleep disorders, or mixed migraine/tension-type headache 1, 2
• Sodium valproate (800-1500 mg/day) or divalproex sodium (500-1500 mg/day): Effective but strictly contraindicated in women of childbearing potential due to teratogenic effects 1, 2
• Flunarizine (where available) 1

Third-Line Options: CGRP Monoclonal Antibodies

Consider when first- and second-line treatments have failed or are contraindicated:

• Erenumab, fremanezumab, galcanezumab (strong recommendations for episodic or chronic migraine) 1
• Eptinezumab (intravenous; weaker evidence) 1
• Requires 3-6 months to assess efficacy (longer than traditional preventives) 1

OnabotulinumtoxinA

• Recommended for chronic migraine prevention ONLY (≥15 headache days/month) 1
• Specifically NOT recommended for episodic migraine 1

Critical Implementation Principles

Dosing Strategy

• Start low and titrate slowly to minimize side effects and improve tolerability 1, 2
• Allow minimum 2-3 months at therapeutic dose before declaring treatment failure 1, 2

Monitoring Success

• Use headache diaries to track frequency, severity, duration, disability, and medication use 1, 2
• Define success as ≥50% reduction in monthly migraine days 2

Duration of Therapy

• After 6-12 months of successful therapy, consider tapering to determine if preventive can be discontinued 1

Non-Pharmacological Adjuncts

Consider as adjuncts to medication or when medications are contraindicated:

• Neuromodulatory devices 1
• Biobehavioral therapy (cognitive behavioral therapy) 1, 2
• Acupuncture (though not superior to sham in controlled trials) 1

Special Population: Children and Adolescents

• Discuss with families that placebo was as effective as studied medications in many pediatric trials 4
• Consider preventive therapy for frequent or disabling headaches 4
• Options include: amitriptyline combined with cognitive behavioral therapy, topiramate, or propranolol 4, 2
• Counsel about teratogenic effects of topiramate and valproate in adolescents; advise effective contraception and folate supplementation 4

Common Pitfalls to Avoid

• Do NOT declare treatment failure before 2-3 months of adequate dosing 2
• Do NOT start with too high a dose, leading to poor tolerability and discontinuation 1
• Do NOT fail to recognize medication overuse headache from frequent acute medication use, which interferes with preventive treatment 1
• Do NOT allow increased acute medication frequency in response to preventive treatment failure 2
• Do NOT combine topiramate and amitriptyline without adequate monotherapy trials first (increased adverse events) 2
• Do NOT use valproate in women of childbearing potential without extensive counseling about teratogenicity, effective contraception, and folate 1, 2