Migraine Headache Prophylaxis

Hien Ha, PharmD, and Annika Gonzalez, MD, Christus Santa Rosa Family Medicine Residency Program, San Antonio, Texas

Migraines impose significant health and financial burdens. Approximately 38% of patients with episodic migraines would
benefit from preventive therapy, but less than 13% take prophylactic medications. Preventive medication therapy reduces
migraine frequency, severity, and headache-related distress. Preventive therapy may also improve quality of life and prevent
the progression to chronic migraines. Some indications for preventive therapy include four or more headaches a month,
eight or more headache days a month, debilitating headaches, and medication-
overuse headaches. Identifying and managing environmental, dietary, and
behavioral triggers are useful strategies for preventing migraines. First-line med-
ications established as effective based on clinical evidence include divalproex,
topiramate, metoprolol, propranolol, and timolol. Medications such as ami-
triptyline, venlafaxine, atenolol, and nadolol are probably effective but should
be second-line therapy. There is limited evidence for nebivolol, bisoprolol,
pindolol, carbamazepine, gabapentin, fluoxetine, nicardipine, verapamil,
nimodipine, nifedipine, lisinopril, and candesartan. Acebutolol, oxcarbazepine,
lamotrigine, and telmisartan are ineffective. Newer agents target calcitonin
gene-related peptide pain transmission in the migraine pain pathway and have
recently received approval from the U.S. Food and Drug Administration;​​​how-

Illustration by Scott Bodell

ever, more studies of long-term effectiveness and adverse effects are needed.
The complementary treatments petasites, feverfew, magnesium, and riboflavin are probably effective. Nonpharmacologic
therapies such as relaxation training, thermal biofeedback combined with relaxation training, electromyographic feedback,
and cognitive behavior therapy also have good evidence to support their use in migraine prevention. (Am Fam Physician.
2019;​99(1):17-24. Copyright © 2019 American Academy of Family Physicians.)

The disabling nature of migraine headaches causes fre- Migraines are distinguished from other headache types
quent visits to outpatient clinic and emergency department by the following attributes:​​​lasting four to 72 hours;​​​unilat-
settings, imposing significant health and financial burdens. eral location;​​​pulsating quality;​​​moderate to severe inten-
Headaches rank among the top five reasons for emergency sity;​​​aggravated by physical activity;​​​and associations with
department visits and top 20 reasons for outpatient visits.1 nausea, vomiting, phonophobia, or photophobia. Migraine
The prevalence of migraines is an estimated 16%;​​​they are headaches may be preceded by aura symptoms.3 Episodic
more common in women, with a peak sex prevalence ratio and chronic migraines are part of a spectrum of migraine
of 3:​​​1.1 Approximately 38% of persons who have episodic disorders but are distinct clinical entities4 (Table 13,4).
migraines would benefit from prophylactic therapy, but Chronic migraines are less common (1% to 5% of patients
only 3% to 13% obtain it.2 with migraines) and are defined as having headaches at least
15 times a month for at least three months.3 Limited data
guide treatment for chronic migraines, which are associated
Additional content at https://​​w ww.aafp.org/afp/2019/0101/
p17.html. with a poor quality of life.4 Preventive therapy for episodic
CME This clinical content conforms to AAFP criteria for con-
migraines may decrease headache frequency, severity, and
tinuing medical education (CME). See CME Quiz on page 11. prevent progression to chronic migraines.
Author disclosure:​​​​ No relevant financial affiliations.
Identifying and Managing Triggers
Patient information:​​​ A handout on this topic is available at
https://​​family​doctor.org/condition/migraines/. Migraine triggers are specific to individuals. A headache
diary is a helpful tool to aid patients in identifying particular

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 MIGRAINE HEADACHE PROPHYLAXIS

triggers, monitoring the number of headache days, and doc- Caffeine can be helpful in relieving headache pain, but
umenting therapeutic response. Common triggers include acute withdrawal from daily consumption can be a trigger
delayed or missed meals, menstruation, stress, weather (Table 25,6). After triggers are identified, a physician can rec-
changes, alcohol, and certain odors. Common dietary trig- ommend ways to manage these triggers, such as avoiding
gers include chocolate, soft cheeses, red wine, and artificial certain foods, establishing regular mealtimes, managing
sweeteners and additives such as monosodium glutamate.5,6 stress, and evaluating and treating underlying sleep disor-
ders or psychiatric conditions.

TABLE 1 Initiating Preventive Therapy

Considerations for starting prophy-
International Classification of Headache Disorders, 3rd Edition lactic treatment include the following:​​​
Classification Determinants having four or more headaches a month
or at least eight headache days a month,
Migraine A. At least five attacks fulfilling criteria B, C, and D
without aura debilitating attacks despite appro-
B. Attack lasting 4 to 72 hours (untreated or unsuccessfully treated)
priate acute management, difficulty
C. Having at least two of these characteristics:​​​aggravation by or
causing avoidance of routine physical activity (e.g., walking or
tolerating or having a contraindication
climbing stairs), moderate or severe pain intensity, pulsating qual- to acute therapy, medication-overuse
ity, unilateral location headache (Table 13,4), patient pref-
D. Having at least one of these conditions during the headache:​​​ erence, or the presence of certain
nausea and/or vomiting, phonophobia or photophobia migraine subtypes (i.e., hemiplegic
Migraine with A. At least two attacks fulfilling criteria B and C migraine;​​​ migraine with brainstem
aura B. Having one or more of these fully reversible aura symptoms:​​​
aura;​​​ migrainous infarction;​​​ or fre-
brainstem, motor, retinal, sensory, speech and/or language, visual quent, persistent, or uncomfortable
C. Having at least two of these characteristics:​​​at least one aura symp- aura symptoms) (Figure 17).8
tom spreads gradually over at least 5 minutes and/or two or more
symptoms occur in succession; each individual aura symptom lasts
5 to 60 minutes; at least one aura symptom is unilateral; the aura is
accompanied or followed within 60 minutes by headache TABLE 2
Episodic Characterized by those with migraine who have zero to 14 headache Common Migraine Triggers
migraine* days per month4
Additives
Chronic A. Headaches at least 15 days per month for more than 3 months Alcohol
migraine and fulfilling criteria B and C
Artificial sweeteners (e.g., aspartame)
B. Occurring in patients with at least five attacks fulfilling criteria in
the Migraine with Aura or Migraine without Aura sections Caffeine (overconsumption or acute
withdrawal from regular use)
C. For at least 8 days per month for more than 3 months, fulfills any
of the following:​​​ Delayed/missed meals

1. Criteria C and D for Migraine without Aura section Exercise

2. Criteria B and C for Migraine with Aura section Foods (e.g., chocolate, soft cheese)

3. Believed by the patient to be migraine at onset and relieved by Light

triptan or ergot derivative Menses
Odors (e.g., perfumes)
Medication-​ A. Headache occurring on at least 15 days per month in a patient
overuse with a pre-existing headache disorder Oral contraceptives
headache B. Regular overuse for more than three months of one or more Psychiatric comorbidities
drugs that can be taken for acute and/or symptomatic treatment Red wine
of headache† Sleep disturbances (e.g., obstructive
sleep apnea, insomnia)
*—Episodic migraine is not recognized in the International Classification of Headache Disorders,
3rd ed., but its definition in the literature is recognized as zero to 14 headache days per month. Smoke
†—Regular intake of ergotamine, triptan, or opioid medications for a total of at least 10 days Stress
per month or nonopioid medications (e.g., acetaminophen, nonsteroidal anti-inflammatory
Weather changes
drugs) for at least 15 days per month.
Information from references 3 and 4. Information from references 5 and 6.

18  American Family Physician www.aafp.org/afp Volume 99, Number 1 ◆ January 1, 2019
 MIGRAINE HEADACHE PROPHYLAXIS

Once the need for prophylactic treatment is established, days, a significant decrease in the duration of attacks, or an
adhering to the following consensus-based principles of improvement in response to acute therapy.
care may improve the success of preventive therapy.8 •  Allow an adequate trial for each treatment. The patient
•  Start therapy with medications that have the highest may see improvement in six to eight weeks, but it may take
level of evidence-based effectiveness (Table 39 and eTable A). up to six months for full effect.5
•  Consider comorbid conditions when selecting a medi- •  Reevaluate therapy. Patient may have partial response
cation;​​​choose medications that also treat these conditions. and require dose titration. Consider changing therapy if no
Avoid agents that are contraindicated or that may exacer- response occurs after two months.
bate coexisting conditions (Table 48,10 and Table 58). •  Discontinue therapy. If headaches are controlled for at
•  Start with the lowest effective dose and titrate every two least six to 12 months, consider slowly tapering and discon-
to four weeks until therapeutic effect or until patient devel- tinuing therapy.
ops adverse effects (Table 48,10 and Table 58).
• Set realistic goals. Successful treatment is defined Preventive Medication
as a 50% reduction in the number of headache attacks or Several medications have been studied for the prevention of
episodic migraines. Based on guidelines from the American
Headache Society and the American Academy of Neurol-
FIGURE 1 ogy, agents with the most quality evidence to support their
use should generally be considered first for migraine pre-
Indication for prophylaxis therapy vention9,11 (Table 39).
≥ 4 headaches per month or ≥ 8 headache days per month
Debilitating attacks despite acute therapy BETA BLOCKERS
Difficulty tolerating or contraindication to acute therapy Close to 60 trials confirm the effectiveness of proprano-
Overuse of acute medication lol.7,9 Based on nine randomized placebo-controlled trials,
Patient preference for fewer attacks the overall relative risk of response to propranolol was 1.94
Presence of migraine subtypes
(95% confidence interval [CI], 1.61 to 2.35).12 Metoprolol is
also effective. In four studies evaluating the use of meto-
Consider first-line therapy: divalproex (Depakote), topi- prolol compared with placebo, the pooled mean difference
ramate (Topamax), propranolol, metoprolol, timolol in headaches per month was –0.94 (95% CI, –1.4 to –0.46).13
May consider complementary therapy: petasites Timolol has demonstrated effectiveness compared with
placebo in three studies.7,9,11 Atenolol and nadolol (Corgard)
Titrate dose every 2 to 4 weeks until effective; full benefit have adequate evidence to support their effectiveness.9
may take 2 to 6 months; monitor for adverse effects Less Evidence-Based Options. Nebivolol (Bystolic) has
one randomized controlled trial to support its use and is
If agent is not effective after 2 months or at
maximal dose or if intolerable adverse effects
occur, consider a different first-line agent
TABLE 3

If no first-line agent is effective or if intolerable adverse Recommended Medications for Episodic

effects occur, consider combination of two first-line agents Migraine Prevention
First-line agents (established Second-line agents (probably
efficacy based on evidence) effective based on evidence)
If no first-line agent or combination is effective or if intol-
erable adverse effects occur, consider second-line therapy: Divalproex (Depakote) Amitriptyline
amitriptyline, venlafaxine, atenolol, nadolol (Corgard) Frovatriptan (Frova)* Atenolol
May consider complementary therapy: feverfew or riboflavin
Metoprolol Nadolol (Corgard)
Propranolol Naratriptan (Amerge)*
Algorithm for initiating pharmacologic migraine Timolol Venlafaxine
prophylaxis. Topiramate (Topamax) Zolmitriptan (Zomig)*
Adapted with permission from Modi S, Lowder DM. Medications for
*—For menstrual-associated migraines.
migraine prophylaxis [published correction appears in Am Fam Phy-
sician. 2006;​​​74(10):​​​1685]. Am Fam Physician. 2006;​​​73(1):​​​73. Information from reference 9.

January 1, 2019 ◆ Volume 99, Number 1 www.aafp.org/afp American Family Physician 19

 MIGRAINE HEADACHE PROPHYLAXIS
TABLE 4

Dosing Recommendations for First- and Second-Line Medications for Episodic Migraine Prevention
Cost per month
for minimum
Drug Starting dose Daily dosage Adverse effects Contraindications daily dosage*

Beta blockers
Atenolol 50 mg 100 mg daily Bradycardia, depression, fatigue, Asthma, brady- $10
hypotension, impotence, lethargy cardia, COPD

Metoprolol 50 mg two 37.5 to 200 mg Bradycardia, depression, fatigue, Asthma, brady- $20
times daily daily hypotension, impotence, lethargy cardia, COPD

Nadolol 40 to 80 mg 20 to 160 mg Bradycardia, depression, fatigue, Asthma, brady- $40 ($140)

(Corgard) daily hypotension, impotence, lethargy cardia, COPD

Propranolol 40 mg divided 120 to 240 mg Bradycardia, depression, fatigue, Asthma, brady- $50
two to three two to three hypotension, impotence, lethargy cardia, COPD
times daily times daily

Timolol 20 to 30 mg 20 to 30 mg daily Bradycardia, depression, fatigue, Asthma, brady- $50

or 10 to 15 mg hypotension, impotence, lethargy cardia, COPD
two times daily

Anticonvulsants
Divalproex 250 mg 250 to 500 mg Alopecia, asthenia, dizziness, Liver disease, $15 ($200)
(Depakote) twice daily hepatic failure, nausea (common), pregnancy
pancreatitis, somnolence, thrombo-
Divalproex ER 500 mg 500 to 1,000 mg $50 ($200)
cytopenia, tremors, weight gain
(Depakote ER) once daily

Topiramate 15 to 25 mg 25 to 200 mg Paresthesia (common), decreased Pregnancy $15 ($180)

(Topamax) once daily appetite, difficulty with memory
and concentration, fatigue, kidney
stones, language problems, meta-
bolic acidosis, nausea

Antidepressants
Amitriptyline 10 mg 25 to 150 mg Blurry vision, constipation, Do not use $10
once daily decreased seizure threshold, dry within 14 days of
mouth, orthostatic hypotension, QT MAOI, avoid in
prolongation, sedation, tachycardia, acute myocardial
urinary retention infarction, sei-
zure disorder

Venlafaxine 37.5 mg 150 mg once Dry mouth, hypertension, insomnia, Do not use $30
daily mydriasis, nausea, nervousness, within 14 days of
seizures MAOI

COPD = chronic obstructive pulmonary disease;​​​ER = extended release;​​​MAOI = monoamine oxidase inhibitor.
*—Estimated retail price of one month’s treatment based on information obtained at https://​​w ww.goodrx.com (accessed September 25, 2018).
Information from references 8 and 10; drug information from Prescription Drug Cards. Doses provided are for doses studied.

considered possibly effective. This study found that nebiv- trials evaluating divalproex and placebo, the risk ratio for
olol and metoprolol were equally effective in reducing responders was 2.18 (95% CI, 1.78 to 3.72).15 A more recent
migraine attacks in the final four weeks of a 14-week trial.14 study evaluated the use of extended-release divalproex com-
There are not enough studies to determine the effectiveness pared with placebo in 239 patients. The divalproex group had
of bisoprolol (Zebeta) and pindolol. Acebutolol (Sectral) is a statistically greater mean reduction in four-week migraine
not considered effective for migraine prevention.9 headache rates from baseline when compared with placebo,
1.2 vs. 0.6 fewer headaches, respectively.16
ANTICONVULSANTS AND ANTIEPILEPTICS Topiramate (Topamax) is an antiepileptic supported by
Ten clinical studies have consistently demonstrated that substantial data. Based on a Cochrane review including
valproic acid in the form of valproate (not available in the 17 trials, topiramate reduces the frequency of headaches
United States) or divalproex (Depakote) is effective. In four and is two times more likely to reduce headache frequency

20  American Family Physician www.aafp.org/afp Volume 99, Number 1 ◆ January 1, 2019
 MIGRAINE HEADACHE PROPHYLAXIS
TABLE 5

Clinical Pearls for Drug Therapy of Migraine Prevention

Beta blockers Good option for patients with hypertension, angina, or ischemic heart disease;​​​the most commonly used drug
(e.g., proprano- class for migraine prevention.
lol, metoprolol) Adverse effects:​​​Depression, erectile dysfunction, fatigue, lethargy, nightmares;​​​monitor for bradycardia and
hypotension.
Avoid use in patients with asthma, atrioventricular conduction defects, bradycardia, and chronic obstructive pul-
monary disease.
Dosing:​​​Start low and monitor heart rate and blood pressure.

Amitriptyline Good option for patients with depression or insomnia;​​​an effective drug class, but it has the highest risk of adverse
effects.
Adverse effects:​​​Sedation and dose-related anticholinergic adverse effects are most common (blurry vision, con-
stipation, dry mouth, palpitations, tachycardia, urinary retention);​​​cardiac conduction abnormalities, orthostatic
hypotension, QT prolongation, and weight gain can also occur.
Avoid use in older patients or in patients with benign prostatic hypertrophy, glaucoma, or seizure disorder (lowers
seizure threshold);​​​use caution when prescribing to patients with cardiac disease.
Dosing:​​​Start with low dose at bedtime;​​​patients with comorbid depression may eventually require higher doses to
treat the depression.

Venlafaxine Good option for patients with comorbid depression or anxiety.

Adverse effects:​​​Nausea and vomiting are common.
Avoid use in patients with uncontrolled hypertension because it may increase blood pressure.
Dosing:​​​When discontinuing, taper slowly to avoid withdrawal symptoms.

Divalproex Good option for patients with seizure disorder or bipolar disorder.
(Depakote) Adverse effects:​​​Gastrointestinal distress, nausea, somnolence, and vomiting are most common. Tremors and
alopecia can occur later in course of therapy. Risk for liver failure, pancreatitis, and thrombocytopenia warrants
periodic laboratory monitoring. Consider monitoring valproic acid levels if nonadherence is suspected.
Avoid use in patients who are pregnant (risk for neural tube defects) or who have liver disease.
Dosing:​​​Start at 250 to 500 mg per day;​​​monitor valproic acid levels if adherence is a concern.

Topiramate Good option for patients with seizure disorder.

(Topamax) Adverse effects:​​​Paresthesia is most common. Abdominal pain, fatigue, impaired memory and concentration, kid-
ney stones, nausea, taste changes, vomiting, and weight loss are also common. Although rare, because of risk for
acute myopia and angle-closure glaucoma, monitor for eye pain. Risk for hepatotoxicity and metabolic acidosis
warrants periodic laboratory monitoring.
Avoid use in patients who are pregnant (risk for oral clefts) or who have glaucoma, kidney stones, or liver disease.
Dosing:​​​Increase 15 to 25 mg per week to reach 50 to 100 mg. May increase further if needed. Doses > 200 mg
may reduce the effectiveness of oral contraceptives.

Information from reference 8.

by 50% or more when compared with placebo.17 In head- differences in headache frequency or percent responders.19
to-head clinical studies, topiramate was as effective as Because of these mixed results, guidelines do not support or
amitriptyline and propranolol.17,18 In one study, there was discourage the use of gabapentin. Based on available studies,
no significant difference in the reduction of mean monthly oxcarbazepine (Trileptal) is categorized as possibly ineffec-
migraine episodes from baseline between topiramate tive, and lamotrigine (Lamictal) is considered ineffective.9
and amitriptyline.18 Based on pooled data from two trials
comparing topiramate and propranolol, no significant dif- ANTIDEPRESSANTS
ference in headache frequency occurred.17 Tricyclic antidepressants, including amitriptyline, dox-
Less Evidence-Based Options. Carbamazepine (Tegretol) epin, nortriptyline (Pamelor), and protriptyline, are used in
is an antiepileptic that has been studied for use in migraine migraine prevention, but only amitriptyline has substantial
prevention and is considered possibly effective. Gabapentin data from about 12 randomized trials that support its effec-
(Neurontin) has been compared with placebo in six random- tiveness.20 However, because of a high incidence of adverse
ized controlled trials with mixed results. Four studies found effects, it is classified as only probably effective.8,9 Venlafax-
no differences in headache frequency or percent respond- ine is considered probably effective based on two studies.
ers, whereas two found small, but statistically significant, One study was a randomized double-blind crossover study

January 1, 2019 ◆ Volume 99, Number 1 www.aafp.org/afp American Family Physician 21

 MIGRAINE HEADACHE PROPHYLAXIS

comparing venlafaxine and amitriptyline. Venlafaxine subcutaneous erenumab, 70 mg and 140 mg given monthly,
produced a significant decrease in the number of migraine reduced the baseline mean migraine days per month of 8.3
attacks per month as well as a decrease in the duration and by 3.2 and 3.7 days, respectively, compared with 1.8 days in
severity of attacks. There was no significant difference in the placebo group (P < .001). Injection site pain and consti-
effectiveness between venlafaxine and amitriptyline.21 pation were more common in the groups taking erenumab,
Less Evidence-Based Options. Studies of fluoxetine but no statistically significant differences in adverse effects
(Prozac) have demonstrated inconsistent results. Two vs. placebo occurred. More studies are needed to deter-
placebo-controlled studies showed a significant reduction mine its long-term effectiveness and adverse effects.28
in headache and pain scores.9,22 However, in another study, Two additional monoclonal antibodies against calcitonin
fluoxetine was not effective in reducing headache frequency gene-related peptide (fremanezumab-vfrm [Ajovy] and gal-
or pain scores.23 Because of the conflicting data, its use is not canezumab-glnm [Emgality]) are approved for migraine
supported or discouraged by guidelines.9 prevention.

CALCIUM CHANNEL BLOCKERS Complementary Therapy

The quality of evidence for calcium channel blockers in Petasites, an extract of the butterbur plant, is effective for
migraine prevention is weak. Nicardipine (Cardene) is clas- the prophylactic treatment of migraines in dosages of 50 to
sified as possibly effective. In past guidelines, verapamil and 75 mg twice a day.29 The most common adverse effects are
nimodipine (Nimotop) were originally considered effective gastrointestinal upset and belching;​​​less often, hepatotoxic-
for migraine prophylaxis. However, on reevaluation of pre- ity may occur. Although the American Academy of Neurol-
vious studies, supporting data for verapamil and nimodip- ogy retired their 2012 guidelines on complementary therapy
ine are now considered insufficient. Likewise, data regarding secondary to serious safety concerns regarding butterbur,30
nifedipine are inadequate or conflicting.9 the Canadian Headache Society still strongly recommends
its use. The Canadian Headache Society cautions that only
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS commercially prepared products that have passed federal
AND ANGIOTENSIN RECEPTOR BLOCKERS health inspection should be used.29 Other treatments that
Three studies have been conducted with angiotensin- are probably effective are riboflavin (400 mg daily) and
converting enzyme inhibitors and angiotensin receptor feverfew (Tanacetum parthenium). Coenzyme Q10, 100 mg
blockers for migraine prevention. One study demonstrated three times a day, and magnesium dicitrate, 600 mg daily,
that patients taking lisinopril reported fewer days with are possibly effective.29,31
migraines compared with those taking a placebo (14.5 days
vs. 18.5 days [95% CI, 9 to 34 days]).24 Studies for angioten- Nonpharmacologic Therapy
sin receptor blockers have been conflicting. Candesartan A U.S. Headache Consortium meta-analysis concluded
(Atacand) was associated with reduced migraine days and that relaxation training, thermal biofeedback combined
hours as secondary end points in one study, whereas telmis- with relaxation training, electromyographic biofeedback,
artan (Micardis) failed to show a significant reduction in and cognitive behavior therapy may be considered as treat-
migraine days compared with placebo in another study.25,26 ment options for the prevention of migraine. Additionally,
Lisinopril and candesartan are possibly effective, and tel- behavioral therapy (i.e., relaxation, biofeedback) may be
misartan is possibly ineffective for migraine prevention.9 combined with preventive drug therapy (i.e., proprano-
lol, amitriptyline) for patients to achieve additional clini-
ONABOTULINUMTOXINA cal improvement for migraine relief.11,32 A 2016 Cochrane
OnabotulinumtoxinA (Botox) is ineffective and should not review suggests that adding acupuncture to symptomatic
be offered for preventing episodic migraine. However, there treatment decreases the frequency of headaches and was at
is evidence supporting the use of onabotulinumtoxinA in least as effective as prophylactic medication.33
the prevention of chronic migraines.27
Special Considerations
CALCITONIN GENE-RELATED PEPTIDE THERAPY MENSTRUAL-ASSOCIATED MIGRAINE
Erenumab (Aimovig) was approved by the U.S. Food and For menstrual migraines, starting preventive therapy before
Drug Administration in May 2018 for migraine prevention. the time of expected migraine onset can help prevent dis-
Erenumab was the first approved monoclonal antibody; it ability and reduce severity.34 Frovatriptan (Frova), naratrip-
binds to the calcitonin gene-related peptide receptor, which tan (Amerge), and zolmitriptan (Zomig) all demonstrated
mediates migraine pain transmission. In a six-month study, effectiveness. Frovatriptan has the strongest evidence and

22  American Family Physician www.aafp.org/afp Volume 99, Number 1 ◆ January 1, 2019
 MIGRAINE HEADACHE PROPHYLAXIS

SORT:​​​KEY CLINICAL RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Preventive therapy should be considered in patients having four or more headaches a month or at least C 8
eight headache days a month, significantly debilitating attacks despite appropriate acute management,
difficulty tolerating or having a contraindication to acute therapy, medication overuse headache, patient
preference, or the presence of certain migraine subtypes (i.e., hemiplegic migraine;​​​migraine with brainstem
aura;​​​migrainous infarction;​​​or frequent, persistent, or uncomfortable aura symptoms).

Divalproex (Depakote), topiramate (Topamax), metoprolol, propranolol, and timolol are effective for A 7-9, 11-18
migraine prevention and should be offered as first-line treatment.

Petasites has been established as effective and can be considered for migraine prevention. B 29, 30

Behavioral treatments, such as relaxation training, thermal biofeedback combined with relaxation train- B 11, 32
ing, electromyographic biofeedback, and cognitive behavior therapy, are effective options for migraine
prevention.

Adding acupuncture to symptomatic treatment decreases the frequency of migraine headaches. A 33

A = consistent, good-quality patient-oriented evidence;​​​B = inconsistent or limited-quality patient-oriented evidence;​​​C = consensus,

disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://​​
www.aafp.org/afpsort.

is supported by two clinical studies. In one study, frovatrip- This article updates a previous article on this topic by Modi and
tan groups had a lower incidence of menstrual headaches Lowder.7
during a six-day period vs. placebo (52% with frovatriptan, Data Sources:​​​ The National Guideline Clearinghouse was used
and searched for the key words migraine prevention, migraine
2.5 mg daily, vs. 41% with frovatriptan, 2.5 mg two times a prophylaxis, and botulinum and migraines. The search included
day, vs. 67% with placebo;​​​P < .0001). Naratriptan and zol- all relevant guidelines. A PubMed search was completed in
mitriptan have been found beneficial in one study.9,34 Clinical Queries using the key words migraine prevention and
migraine prophylaxis. A PubMed search was also completed
CHILDREN using the key words author name/publication year for relevant
trials noted in various guidelines. The aforementioned searches
Only flunarizine has sufficient evidence to be considered included randomized controlled trials, clinical trials, guidelines,
probably effective for migraine prevention in children, but it and reviews. There were also searches using Essential Evidence
is not available in the United States. Agents commonly pre- Plus, the Agency for Healthcare Research and Quality evidence
scribed for children, such as propranolol and topiramate, reports, Cochrane database, National Center for Complemen-
have conflicting results in studies. Other agents, including tary and Integrative Health, and UpToDate. Search dates:​​​July 29,
2017;​​​ August 8-9, 2017;​​​ September 13-16, 2017;​​​ October 20-26,
cyproheptadine, amitriptyline, valproic acid (Depakene), 2017; and October 10, 2018.
and levetiracetam (Keppra), have insufficient data in chil-
dren. More quality randomized controlled trials are needed
The Authors
in this population.35
HIEN HA, PharmD, is an associate professor at the University
PREGNANCY of the Incarnate Word, Feik School of Pharmacy, and a clin-
ical pharmacist specialist and faculty at Christus Santa Rosa
Guidelines on preventing migraines in pregnancy suggest Family Medicine Residency Program, San Antonio, Tex.
considering nonpharmacologic options before drug ther-
apy. If drug therapy is needed, an agent with the lowest risk ANNIKA GONZALEZ, MD, is a faculty physician at Christus
Santa Rosa Family Medicine Residency Program and section
of harm to the fetus can be considered at the lowest effective
chief of pediatrics at Santa Rosa Westover Hills Hospital, San
dose.11 Although there have been reports of intrauterine Antonio.
growth retardation, beta blockers such as propranolol are
generally considered safe in pregnancy.36,37 Valproic acid Address correspondence to Hien Ha, PharmD, University of
the Incarnate Word, 4301 Broadway #99, San Antonio, TX
should be avoided in pregnancy because of teratogenic risk.
78209 (e-mail:​​​hha@​​uiwtx.edu). Reprints are not available
Topiramate and angiotensin-converting enzyme inhibitors from the authors.
should be avoided because of potential fetal harm.

January 1, 2019 ◆ Volume 99, Number 1 www.aafp.org/afp American Family Physician 23

 MIGRAINE HEADACHE PROPHYLAXIS

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24  American Family Physician www.aafp.org/afp Volume 99, Number 1 ◆ January 1, 2019
 BONUS DIGITAL CONTENT
MIGRAINE HEADACHE PROPHYLAXIS

eTABLE A

Other Medications (Less Evidence Based)

for Episodic Migraine Prevention
Possibly effective
Candesartan (Atacand)
Carbamazepine (Tegretol)
Lisinopril
Nebivolol (Bystolic)
Nicardipine (Cardene)

Conflicting or inadequate data to support or refute use

Bisoprolol (Zebeta)
Fluoxetine (Prozac)
Gabapentin (Neurontin)
Nifedipine
Nimodipine (Nimotop)
Pindolol
Protriptyline
Verapamil

Ineffective
Acebutolol (Sectral)
Lamotrigine (Lamictal)
Oxcarbazepine (Trileptal)
Telmisartan (Micardis)

Information from Silberstein SD, Holland S, Freitag F, Dodick DW,

Argoff C, Ashman E. Evidence-based guideline update:​​​pharmaco-
logic treatment for episodic migraine prevention in adults:​​​Report
on the Quality Standards Subcommittee of the American Academy
of Neurology and the American Headache Society [published cor-
rection appears in Neurology. 2013;​​​80(9)871]. Neurology. 2012;​​​
78(17):​​​1337-1345.

January 1, 2019 ◆ Volume 99, Number 1 www.aafp.org/afp American Family Physician 24A