From the Guidelines
For migraine prophylaxis when experiencing sporadic migraines occurring 1-2 times per month, I recommend starting with a first-line preventive medication such as propranolol 20-40mg twice daily, topiramate 25-100mg daily, or candesartan, as these have been shown to be effective in reducing migraine frequency and severity 1. These medications should be taken daily, not just when headaches occur, and typically require 2-3 months of consistent use to determine effectiveness. While continuing Advil (ibuprofen) or Tylenol (acetaminophen) for acute attacks, limit these to no more than 2-3 days per week to avoid medication overuse headaches. Non-medication approaches are also important:
- maintain regular sleep patterns
- stay hydrated
- identify and avoid personal triggers (certain foods, stress, irregular meals)
- consider stress management techniques like meditation or yoga. These preventive medications work through various mechanisms - propranolol blocks pain signals and dilated blood vessels, topiramate affects neurotransmitters and nerve excitability. If the first medication tried doesn't reduce migraine frequency by at least 50% after 2-3 months at an adequate dose, discuss with your doctor about trying an alternative option or adding supplements like magnesium 400-500mg daily or riboflavin (vitamin B2) 400mg daily, or considering CGRP monoclonal antibodies as third-line medications 1. It's also essential to educate patients about the control of acute attacks and preventive therapy and engage them in the formulation of a management plan, as this can lead to better outcomes and patient satisfaction 2. Given the patient's current situation, with migraines occurring sometimes 2 a month and then every month and every other month, and considering the patient's preference for a more effective prophylactic treatment, starting with a first-line preventive medication is a reasonable approach, as it has been shown to be effective in reducing migraine frequency and severity, and improving quality of life 1.
From the FDA Drug Label
Migraine: In a 34-week, placebo-controlled, 4-period, dose-finding crossover study with a double-blind randomized treatment sequence, 62 patients with migraine received propranolol 20 to 80 mg 3 or 4 times daily The headache unit index, a composite of the number of days with headache and the associated severity of the headache, was significantly reduced for patients receiving propranolol as compared to those on placebo
- Propranolol is effective for migraine prophylaxis, as it significantly reduced the headache unit index in a placebo-controlled study 3.
- The study suggests that propranolol can be used as a prophylactic treatment for migraines, which may be beneficial for patients experiencing sporadic migraines.
- The dosage of propranolol used in the study was 20 to 80 mg 3 or 4 times daily.
From the Research
Migraine Prophylactic Treatment Options
The available evidence suggests that several medications can be used for migraine prophylactic treatment, including:
- β-blockers, such as propranolol and timolol 4, 5, 6
- Anticonvulsants, such as topiramate and valproate 4, 5, 7, 6
- Antidepressants, such as amitriptyline 4, 5, 7, 6
- Calcium channel antagonists 4, 5
- Neurotoxins, such as botulinum toxin A, although its effectiveness is still debated 5, 7, 6
Choosing a Prophylactic Treatment
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 4, 5, 7. Lifestyle advice, such as maintaining a regular lifestyle, managing stress, and avoiding trigger factors, should also be considered 5, 7.
First-Line and Second-Line Treatments
First-line treatments for migraine prophylaxis include β-blockers, flunarizine, topiramate, valproic acid, and amitriptyline 5, 7, 6. Second-line treatments, which have less efficacy and evidence, include venlafaxine, gabapentin, naproxen, butterbur root, riboflavin, and magnesium 7, 6.
Non-Pharmacological Treatments
Non-pharmacological treatments, such as relaxation techniques, bio-feedback, cognitive behavioral therapy, and acupuncture, may also be effective in migraine prophylaxis, although they require more specialist time or technical devices 7.