MIGRN PREVENTION

Migraine preventatives: an overview

Drug class	Drug	Side effects & contraindications	Target dose	Regimen
Beta blocker	Propranolol (alternatively atenolol or metoprolol)	Fatigue, depression, weight gain, bradycardia, impotence, orthostasis. Avoided in COPD/asthma, diabetes mellitus, peripheral vascular disease and those with bradyarrhythmias	80 mg BD (Atenolol 50–200 mg per day) (Metoprolol 100–200 mg per day)	Start 40 mg bd, titrate up to 160–320 mg daily
Serotonin antagonist	Pizotifen	Drowsiness, weight gain, dry mouth, urinary retention and manufacturers suggest avoiding in people with glaucoma, urinary retention, renal dysfunction and epilepsy	3 mg daily	Start at 0.5 mg OD, increase by 0.5 mg every 1–2 weeks
Antidepressant	Tricyclic Amitriptyline (alternatively dosulepin or nortriptyline)	Sedation, weight gain, dry mouth. Avoid amitriptyline in people with glaucoma, urinary retention, hypotension and significant cardiovascular comorbidity, including arrhythmias. Use with caution in people with epilepsy	50–75 mg daily	Start 10 mg ON with 10 mg ⇑ every 1–2 weeks
	SNRI Duloxetine (alternatively venlafaxine)	Constipation and diarrhoea, weight gain. Avoid in uncontrolled hypertension	60–90 mg	Start 30 mg, increase every week by 30 mg
Antiepileptic	Topiramate	Topiramate may have cognitive, anxiety and depression-provoking effects and may promote weight loss. Rarely renal calculi and glaucoma. Topiramate induces the metabolism of the combined contraceptive pill	100 mg	Start at 25 mg, ⇑25–50 mg every 1–2 weeks
	Valproate	Valproate can cause weight gain, tremor, alopecia and haematological dyscrasias. It can cause hyperammonaemia and is teratogenic. It should be avoided in liver disease (potentially hepatotoxic)	1000 mg	Start at 200 mg OD, ⇑ 200 mg every 2 weeks
Angiotensin based	Lisinopril	Lisinopril may cause fatigue, dry cough, angioedema, orthostasis or confusion. Hyperkalaemia or bone marrow dysfunction should be avoided	20–40 mg OD	Start at 10 mg OD, ⇑ to 20–40 mg
	Candesartan	Candesartan can cause vertigo and hypotension. It should therefore be avoided in individuals with these disorders	8 mg BD	Start 4 mg OD, titrate by 4 mg every week
Calcium channel blocker	Flunarizine	Weight gain, depression and extrapyramidal effects. May cause galactorrhoea in women concomitantly taking the combined contraceptive pill	5–10 mg	5 mg for a month, then 10 mg
Neutriceutical	Magnesium	In hypermagnesaemia, gastrointestinal (GI) effects, arrhythmia and coma are reported	600 mg daily	–
	Riboflavin	Physiologically limited absorption, limiting adverse effects	400 mg	–
	CoQ10	CoQ10 can cause usually mild GI effects, such as upset stomach	100 mg TDS	–

• BD, twice daily; COPD, chronic obstructive pulmonary disease; OD, once daily; ON, once nightly; SNRI, serotonin norepinephrine reuptake inhibitor; TDS, three times a daily.