From the Guidelines
Migraine prophylaxis is indicated when patients experience frequent or disabling migraines, typically when they have two or more migraine days per month, despite optimized acute treatment, as recommended by the most recent guidelines 1.
Indications for Migraine Prophylaxis
The decision to initiate migraine prophylaxis is based on the frequency and severity of migraine attacks, as well as the patient's response to acute treatment. Key factors to consider include:
- Frequency of migraine attacks: two or more days per month 1
- Severity of migraine attacks: significant disability despite acute treatment 1
- Response to acute treatment: failure of acute treatments or contraindications for such treatments 1
First-Line Prophylactic Medications
First-line prophylactic medications for migraine include:
- Beta blockers: propranolol, metoprolol 1
- Anticonvulsants: topiramate, valproate 1
- Certain antidepressants: amitriptyline 1
Newer Options for Migraine Prophylaxis
CGRP monoclonal antibodies, such as erenumab, fremanezumab, and galcanezumab, are newer options for migraine prophylaxis, given monthly or quarterly 1.
Lifestyle Modifications
Patients should maintain a headache diary to track frequency, severity, and medication use, and continue lifestyle modifications like regular sleep, meals, exercise, and stress management to help manage migraine symptoms.
Goal of Prophylaxis
The goal of migraine prophylaxis is to reduce migraine frequency by at least 50% 1.
From the FDA Drug Label
to prevent headaches in adults with chronic migraine who have 15 or more days each month with headache lasting 4 or more hours each day.
Migraine prophylaxis with onabotulinumtoxinA is indicated in adults with chronic migraine who experience 15 or more days of headache per month, with each headache lasting 4 or more hours 2.
From the Research
Indications for Migraine Prophylaxis
Migraine prophylaxis is indicated for patients with severe and/or frequent migraines, as stated in the study by 3. The decision to start prophylaxis depends on the frequency and severity of migraine attacks, as well as the patient's quality of life and response to acute treatment.
Patient Selection
Patients who may benefit from prophylaxis include those with:
- Frequent migraines (more than 2-3 per month) 4, 5
- Severe migraines with significant disability or impact on daily life 3, 6
- Migraines with aura or other high-risk features 4
Treatment Options
The choice of prophylactic treatment depends on various factors, including efficacy, co-morbidity, side effects, availability, and cost. Some of the commonly used prophylactic treatments include:
- Beta-blockers (e.g., propranolol, timolol) 4, 6
- Antiepileptic drugs (e.g., topiramate, valproate) 4, 5, 6
- Antidepressants (e.g., amitriptyline) 4, 5
- Nutraceuticals (e.g., riboflavin, feverfew) 4
Lifestyle Modifications
In addition to pharmacological treatment, lifestyle modifications are also important in migraine prophylaxis. These include: