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Migraine Headache ProphylaxisAka: Migraine Prophylaxis

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  1. See Also
    1. Migraine Headache
    2. Migraine Headache Management
    3. Migraine Headache Management in Children
    4. Migraine Management Clinic Schedule
    5. Migraine Abortive Management
    6. Migraine Headache Care in the Emergency Department
    7. Headache General Measures
  2. Indications: Frequent Migraine Headaches
    1. Consider in any patient desiring Migraine prophylaxis
    2. Headache frequency
      1. Two or more Headaches monthly
      2. Absolutely indicated for 2 Headache days per week
    3. Headache duration
      1. Prolonged Headaches >2 days with Disability
    4. Headache response to Migraine Abortive Treatment
      1. Refractory to current abortive agents
      2. Intolerance to abortive agents
      3. Overuse of abortive agents
  3. Protocol
    1. Effective prophylaxis reduces Headache frequency by 50%
    2. Trial of prophylactic agent for 2-3 months
    3. Keep Headache diary
    4. Start prophylaxis at low dose and gradually increase
  4. Most Effective Agents for Migraine prophylaxis
    1. Propranolol LA
      1. First choice unless Beta Blocker contraindication
      2. Start: 40-80 mg PO daily
      3. Gradually increase over 3 weeks until effective dose
      4. Maximum: 240 mg orally daily
      5. May substitute with generic Propranolol
        1. Split daily dose into 3-4 divided doses
    2. Timolol
      1. Dose: 10-15 mg orally twice daily
    3. Amitriptyline (Elavil)
      1. Consider in patients with comorbid Tension Headaches
      2. Start: 10 mg PO qhs
      3. Increase every 3 days to 30 mg PO qhs
    4. Valproic Acid and derivatives
      1. See description for adverse effects and monitoring
      2. Divalproex sodium (Depakote) 250-500 mg PO bid
      3. Depakote Extended Release 500-1000 mg daily
      4. Valproic Acid (Depakene) 250-500 mg twice daily
    5. Topiramate (Topamax)
      1. Dosing
        1. Start: 25 mg PO qd for 1 week
        2. Next: 25 mg PO bid for 1 week
        3. Next: 25 mg PO qAM and 50 mg PO qPM for 1 week
        4. Next: 50 mg PO bid
      2. Efficacy
        1. Effective prophylaxis at 100-200 mg per day
        2. Silberstein (2004) Arch Neurol 61:490
        3. Brandes (2004) JAMA 291:965
  5. Beta Blockers
    1. Propranolol (Inderal) long acting 40 to 320 mg PO qd
    2. Timolol (Blocadren) 100-450 mg PO qd
    3. Metoprolol (Lopressor) 100-450 mg PO qd
  6. Calcium Channel Blockers (questionable efficacy)
    1. Less effective than agents above
    2. Verapamil (Calan) 80-120 mg PO tid
  7. Nonsteroidal Antiinflammatory Drugs (NSAIDS)
    1. Aspirin 325 qd
    2. Naproxen sodium (Anaprox) 550 mg PO bid
    3. Indomethacin 50-150 mg/day
  8. Antidepressants
    1. Amitriptyline (Elavil) 30 to 150 mg PO qd
    2. Doxepin (Sinequan) 25-150 mg PO qd
    3. Phenelzine (Nardil) 15 mg PO tid
    4. Selective Serotonin Reuptake Inhibitors (SSRI)
      1. Headache worsens in 30% of cases
      2. Fluoxetine (Prozac) 20-40 mg PO qd
        1. Steiner (1998) Cephalalgia 18:283
  9. Anticonvulsants
    1. Valproic Acid (Depakote) 250 to 750 mg PO bid
      1. Requires Liver Function Test monitoring
    2. Phenytoin (Dilantin) 200-400 mg PO qd
  10. Serotonin Agonist
    1. Cyproheptadine (Periactin) 4-16 mg PO qd
    2. Methysergide (Sansert)
      1. Risk of retroperitoneal fibrosis
      2. Use only with Neurology consultation
  11. Vitamin Supplementation
    1. Petasites hybridus (Butterbur): Petadolex 150 mg/day
      1. May reduce Migraine frequency by 50%
      2. GI intollerance is common
      3. Lipton (2004) Neurology 63:2240
    2. Feverfew 50 to 82 mg daily
    3. Vitamin B2 (Riboflavin) 400 mg/day
      1. Schoenen (1998) Neurology 50:466
    4. Magnesium Oxide 300 mg/day
      1. May reduce severity and duration of Migraines
      2. Wang (2004) {a 14316} 43(6):601
    5. Coenzyme Q10 100 mg PO tid
      1. Reduces Migraines by a third
      2. Sandor (2005) Neurology 64:713
  12. Miscellaneous
    1. Acupuncture
      1. Recent studies: 40% reduction in severity, frequency
    2. Lithium Carbonate (Lithobid) 300 mg PO bid-tid
    3. Lisinopril
      1. Migraine without Aura associated with high ACE Level
      2. Reference
        1. Schrader (2001) BMJ 322:19
  13. References
    1. Jackson (1998) CMEA Internal Medicine Lecture,San Diego
    2. Modi (2006) Am Fam Physician 73:72
    3. Moore (1997) Am Fam Physician 56(8):2039
    4. Noble (1997) Am Fam Physician 56(9):2279
    5. Parsekyan (2000) West J Med 173:341
    6. Polizzotto (2002) J Fam Pract 51(2):161

Migraine prophylaxis (C1142085)

ConceptsTherapeutic or Preventive Procedure (T061)
EnglishMigraine prophylaxis
Spanishprofilaxis de la migraña, profilaxis de la migrana
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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