What is the proper dosage and usage of Tab Flunorm (Flunarizine) 5 mg for migraine prophylaxis?

Tab Flunorm (Flunarizine) 5 mg: Dosage and Usage for Migraine Prophylaxis

For migraine prophylaxis in adults, flunarizine should be initiated at 5 mg once daily at bedtime, with the option to increase to 10 mg daily if needed after 4-8 weeks, though the 5 mg dose is preferred initially due to significantly lower rates of side effects while maintaining efficacy. 1, 2

Standard Dosing Protocol

• Start with 5 mg once daily at bedtime as the initial dose for migraine prevention 2
• The 10 mg daily dose can be used if 5 mg proves insufficient after an adequate trial period of 4-8 weeks 1, 3, 4
• Flunarizine demonstrates dose-dependent side effects, with the 5 mg dose showing significantly better tolerability while maintaining prophylactic efficacy 2

Expected Timeline for Clinical Effect

• Allow at least 4 months of continuous treatment before judging efficacy, as some patients require this extended period to demonstrate full therapeutic benefit 5
• The prophylactic effect of flunarizine increases progressively during the treatment period, with maximal benefit often seen after 16 weeks of continuous use 4
• During the final month of a 16-week treatment period, flunarizine reduced migraine attack frequency by approximately 50% compared to baseline 4

Clinical Efficacy Evidence

• Flunarizine significantly reduces the frequency of migraine attacks and overall headache indices compared to placebo 4, 5
• In classical migraine, flunarizine reduced a corrected migraine index (based on frequency, duration, and severity) by 82% in treated patients 5
• Approximately 76% of patients report clinical benefit from flunarizine treatment, with only 24% reporting no effect 3
• Flunarizine demonstrates efficacy comparable to propranolol and topiramate for migraine prophylaxis 3

Indications for Use

• Chronic migraine is the most common indication 3
• Migraine with aura 3
• Sporadic and familial hemiplegic migraine 3
• New daily persistent headache with migrainous features 3

Side Effect Profile and Management

• Most common adverse effects: tiredness, mood changes (including depression), and weight gain 3, 2
• Side effects are dose-dependent, with 5 mg daily showing significantly lower incidence than 10 mg daily 2
• Only 10.5% of patients discontinue treatment due to adverse effects when doses up to 15 mg are used 3
• Mild daytime sedation may occur but is generally well-tolerated 4
• Depression and extrapyramidal symptoms can occur, particularly in elderly patients 1

Duration of Treatment

• Among patients with available follow-up data, 64% continued flunarizine treatment for more than 1 year, indicating good long-term tolerability and sustained efficacy 3
• Consider a trial period of at least 4 months before discontinuing due to perceived lack of efficacy 5

Critical Considerations

• Flunarizine is widely used in Europe but not licensed in the UK or United States, though it can be obtained through specialized channels 3
• The National Institute for Clinical Excellence (NICE) published supportive guidelines for flunarizine use in migraine in 2014 based on randomized controlled evidence 3
• Avoid use in patients with depression or Parkinson's disease due to risk of worsening these conditions 1

Algorithm for Dose Adjustment

1. Initiate at 5 mg once daily at bedtime 2
2. Continue for 4-8 weeks at this dose while monitoring for efficacy and tolerability 4, 5
3. If inadequate response after 8 weeks and no significant side effects, increase to 10 mg once daily 3, 4
4. Continue treatment for at least 4 months total before declaring treatment failure 5
5. If effective, continue long-term prophylaxis with periodic reassessment 3
6. If significant side effects occur (weight gain, depression, sedation), consider reducing back to 5 mg or discontinuing 2