A) | ||
---|---|---|
TYPE | ACUTE MEDICATIONS | |
First line | Ibuprofen 400 mg, ASA 1000 mg, naproxen sodium 500–550 mg, acetaminophen 1000 mg | |
Second line | Triptans: oral sumatriptan 100 mg, rizatriptan 10 mg, almotriptan 12.5 mg, zolmitriptan 2.5 mg, eletriptan 40 mg, frovatriptan 2.5 mg, naratriptan 2.5 mg
Antiemetics: domperidone 10 mg or metoclopramide 10 mg for nausea | |
Third line | Naproxen sodium 500–550 mg in combination with a triptan | |
Fourth line | Fixed-dose combination analgesics (with codeine if necessary; not recommended for routine use) |
B) | ||||
---|---|---|---|---|
PROPHYLACTIC MEDICATIONS | STARTING DOSE | TITRATION,* DAILY DOSE INCREASE | TARGET DOSE OR THERAPEUTIC RANGE† | NOTES |
First line | ||||
• propranolol | 20 mg twice daily | 40 mg/wk | 40–120 mg twice daily | Avoid in asthma |
• metoprolol | 50 mg twice daily | 50 mg/wk | 50–100 mg twice daily | Avoid in asthma |
• nadolol | 40 mg/d | 20 mg/wk | 80–160 mg/d | Avoid in asthma |
• amitriptyline | 10 mg at bedtime | 10 mg/wk | 10–100 mg at bedtime | Consider if patient has depression, anxiety, insomnia, or tension-type headache |
• nortriptyline | 10 mg at bedtime | 10 mg/wk | 10–100 mg at bedtime | Consider if patient has depression, anxiety, insomnia, or tension-type headache |
Second line | ||||
• topiramate | 25 mg/d | 25 mg/wk | 50 mg twice daily | Consider as a first-line option if the patient is overweight |
• candesartan | 8 mg/d | 8 mg/wk | 16 mg/d | Few side effects; limited experience in prophylaxis |
• gabapentin | 300 mg/d | 300 mg every 3–7 d | 1200–1800 mg/d divided into 3 doses | Few drug interactions |
Other | ||||
• divalproex | 250 mg/d | 250 mg/wk | 750–1500 mg/d divided into 2 doses | Avoid in pregnancy or when pregnancy is possible |
• pizotifen | 0.5 mg/d | 0.5 mg/wk | 1–2 mg twice daily | Monitor for somnolence and weight gain |
• onabotulinumtoxinA | 155–195 units | No titration needed | 155–195 units every 3 mo | For chronic migraine only (headache on ≥ 15 d/mo) |
• flunarizine | 5–10 mg at bedtime | No titration needed | 10 mg at bedtime | Avoid in patients with depression |
• venlafaxine | 37.5 mg/d | 37.5 mg/wk | 150 mg/d | Consider for migraine in patients with depression |
Over the counter | ||||
• magnesium citrate | 300 mg twice daily | No titration needed | 300 mg twice daily | Effectiveness might be limited; few side effects |
• riboflavin | 400 mg/d | No titration needed | 400 mg/d | Effectiveness might be limited; few side effects |
• butterbur | 75 mg twice daily | No titration needed | 75 mg twice daily | Effectiveness might be limited; few side effects |
• coenzyme Q10 | 100 mg 3 times daily | No titration needed | 100 mg 3 times daily | Effectiveness might be limited; few side effects |
ASA—acetylsalicylic acid.
↵* Dosage can be increased every 2 wk to avoid side effects. For most drugs, slowly increase to the target dose; a therapeutic trial requires several months. The expected outcome is reduction not elimination of attacks.
↵† If the target dose is not tolerated, try a lower dose. If the medication is effective and tolerated, continue it for at least 6 mo. If several preventive drugs fail, consider a specialist referral.
Adapted from Toward Optimized Practice.10