Prophylactic Migraine Treatments
NHS Tayside RefGuide
Treatment choice should be tailored to the individual patient dependant on their co-morbidities and lifestyle. There is no one treatment better than another. A reduction of 30-50% in headache severity or frequency is considered a successful treatment. As above, a headache diary should be provided to help quantify this improvement. All treatments should be trialled for at least 3 months at target dose before considering efficacy.
| Starting Dose | Dose Regimen | Target Dose |
Propanalol | 10-20mg twice daily | Increase 10-20mg twice daily every 1-2 weeks | 80mg twice daily |
Amitriptyline | 10mg at night (few hours before bed) | Increase 10mg every 2 weeks | 30-50 daily (max dose 100mg daily) |
Nortriptyline | No formal evidence but less sedating than Amitriptyline so may be considered if Amitriptyline limited by somnolence | ||
Candesartan | 4mg once daily | Increase 4mg every 2 weeks | 16mg daily |
Topiramate | 25mg once daily | Increase 25mg every 2 weeks | 50-100mg twice daily |
Women and topiramate | Women of child-bearing age must be warned of teratogenicity of Topiramate and be on highly effective contraception | ||
Atogepant (1st line CGRP) | 60mg once daily | 60mg once daily | 60mg once daily |
Rimegepant (2nd line CGRP) | 75mg alternate days | 75mg alternate days | 75mg alternate days |