Table 3

Migraine preventatives: an overview

Drug classDrugSide effects & contraindicationsTarget doseRegimen
Beta blockerPropranolol (alternatively atenolol or metoprolol)Fatigue, depression, weight gain, bradycardia, impotence, orthostasis. Avoided in COPD/asthma, diabetes mellitus, peripheral vascular disease and those with bradyarrhythmias80 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 antagonistPizotifenDrowsiness, weight gain, dry mouth, urinary retention and manufacturers suggest avoiding in people with glaucoma, urinary retention, renal dysfunction and epilepsy3 mg dailyStart at 0.5 mg OD, increase by 0.5 mg every 1–2 weeks
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 epilepsy50–75 mg dailyStart 10 mg ON with 10 mg ⇑ every 1–2 weeks
Duloxetine (alternatively venlafaxine)
Constipation and diarrhoea, weight gain. Avoid in uncontrolled hypertension60–90 mgStart 30 mg, increase every week by 30 mg
AntiepilepticTopiramateTopiramate 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 pill100 mgStart at 25 mg, ⇑25–50 mg every 1–2 weeks
ValproateValproate 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 mgStart at 200 mg OD, ⇑ 200 mg every 2 weeks
Angiotensin basedLisinoprilLisinopril may cause fatigue, dry cough, angioedema, orthostasis or confusion. Hyperkalaemia or bone marrow dysfunction should be avoided20–40 mg ODStart at 10 mg OD,
⇑ to 20–40 mg
CandesartanCandesartan can cause vertigo and hypotension. It should therefore be avoided in individuals with these disorders8 mg BDStart 4 mg OD, titrate by 4 mg every week
Calcium channel blockerFlunarizineWeight gain, depression and extrapyramidal effects. May cause galactorrhoea in women concomitantly taking the combined contraceptive pill5–10 mg5 mg for a month, then 10 mg
NeutriceuticalMagnesiumIn hypermagnesaemia, gastrointestinal (GI) effects, arrhythmia and coma are reported600 mg daily
RiboflavinPhysiologically limited absorption, limiting adverse effects400 mg
CoQ10CoQ10 can cause usually mild GI effects, such as upset stomach100 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.