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.