What is the first line medication for headache prevention in a patient experiencing frequent headaches, specifically 10 per month, with no specified past medical history or demographics?

First-Line Medication for Headache Prevention in a Patient with 10 Headaches per Month

For a patient experiencing 10 headaches per month, propranolol (80-240 mg/day) is the first-line medication for prevention, with the strongest evidence base and FDA approval for migraine prophylaxis. 1, 2

Determining the Need for Preventive Therapy

Your patient with 10 headaches per month clearly meets criteria for preventive therapy. The American Academy of Family Physicians recommends initiating prevention when patients experience two or more migraine attacks per month with disability lasting 3 or more days, or when acute medications are used more than twice weekly. 1 With 10 headaches monthly, this patient far exceeds the threshold and requires prophylactic treatment to prevent progression to chronic migraine and medication overuse headache. 3, 1

First-Line Medication Options

The most recent guidelines (2026) establish a clear hierarchy:

Beta-Blockers (Preferred First-Line)

• Propranolol 80-240 mg/day has the strongest evidence with FDA approval and demonstrated efficacy in reducing headache frequency. 1, 2
• Meta-analysis shows propranolol reduces episodic migraine by 1.5 headaches/month and increases the likelihood of achieving 50% reduction in headache frequency (RR: 1.4). 2
• Start with low doses (40-80 mg/day) as 73.5% of patients respond to doses around 1 mg/kg body weight daily, minimizing side effects. 4
• Timolol 20-30 mg/day is an alternative beta-blocker with strong evidence. 1

Topiramate (Alternative First-Line)

• Topiramate 100 mg/day (typically 50 mg twice daily) is particularly advantageous if your patient has obesity, as it promotes weight loss. 1
• Topiramate is the only medication with proven efficacy in randomized controlled trials specifically for chronic migraine. 5
• Start at 25 mg daily and titrate slowly over weeks to minimize cognitive side effects. 3

Candesartan (Alternative First-Line)

• Candesartan is first-line particularly if the patient has comorbid hypertension. 1

Second-Line Options (When First-Line Fails or Contraindicated)

Amitriptyline 30-150 mg/day should be considered second-line, despite older literature suggesting it as first-line. 1 The most recent 2026 guidelines clearly position it after beta-blockers and topiramate. However, amitriptyline moves to first-line consideration if your patient has:

• Comorbid depression or anxiety (treats both conditions simultaneously) 3, 1
• Mixed migraine and tension-type headache features (superior to propranolol for this specific presentation) 3
• Sleep disturbances (sedating effects are beneficial) 3

Start amitriptyline at 10-25 mg at bedtime and titrate slowly to 30-150 mg/day over weeks to months. 3 Common side effects include weight gain, drowsiness, dry mouth, and constipation. 3

Critical Implementation Points

Adequate Trial Duration

• Allow 2-3 months at therapeutic dose before declaring treatment failure. 3, 1 This is the most common pitfall—clinicians discontinue medications prematurely.

Avoid Medication Overuse Headache

• Educate your patient to limit acute medications to less than twice per week (≤10 days/month for triptans, ≤15 days/month for NSAIDs). 3, 1
• Medication overuse headache interferes with preventive treatment effectiveness and worsens headache frequency. 1

Titration Strategy

• Start low and increase slowly to minimize side effects and improve adherence. 1
• For propranolol: begin 40-80 mg/day, increase every 1-2 weeks as tolerated. 4
• For topiramate: begin 25 mg daily, increase by 25 mg weekly. 3
• For amitriptyline: begin 10-25 mg at bedtime, increase by 10-25 mg every 1-2 weeks. 3

Monitoring and Reassessment

Have your patient maintain a headache diary tracking attack frequency, severity, duration, disability, and treatment response. 1 This is essential because patients often underreport milder headaches and cannot accurately recall monthly headache frequency without documentation. 5

After 6-12 months of successful therapy (defined as ≥50% reduction in monthly headache days), consider tapering preventive medication to determine if it can be discontinued. 1

What to Avoid

• Do not use valproate/divalproex in women of childbearing potential due to teratogenic effects, despite its efficacy. 1
• Do not start with CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab)—these are third-line options reserved for patients who have failed 2-3 oral preventive medications, and cost $5,000-$6,000 annually. 1
• Do not use onabotulinumtoxinA for episodic migraine (it is specifically contraindicated); it is only approved for chronic migraine (≥15 headache days/month). 5, 1