Migraine preventives : doses, side effects and contra-indications
Migraine Canada (MC) is a patient association and does not provide medical advice. Nevertheless, basics on medications are public knowledge and many people ask about this type of medical information. The medications provided in the table below are given as general reference. Any decision to take a medication should be discussed with a health care provider.
Table : Migraine Preventives
| Usual dose | Main side effects | Choose for patients with | Avoid in patients with | |
| Frequently used (brand name) | ||||
| Amitriptyline Elavil Nortriptyline Aventyl |
10 to 50 mg at bedtime | Weight gain Drowsiness Confusion Urinary retention Constipation Dry mouth, eyes Orthostatic hypotension |
Insomnia Other pain Tension type headache *no effect on depression at lower doses |
Obesity Glaucoma Prostate disease Heart block Bipolar disorder Elderly |
| Propranolol Inderal Nadolol Corgard |
80 to 160 mg daily (slow release or BID) | Fatigue Reduced exercise tolerance Weight gain Orthostatic hypotension Sexual dysfunction Nightmares |
Hypertension Anxiety Essential tremor |
Raynaud Asthma Heart block Hypotension bradycardia |
| Candesartan Atacand |
8 to 16 mg once daily | Hypotension Dizziness |
Hypertension | Hypotension |
| Topiramate Topamax |
50 to 200 mg daily | Cognitive difficulties Paresthesias Weight loss Kidney stones Anxiety, mania Visual disturbances Glaucoma (rare) |
Obesity Epilepsy Essential tremor Chronic migraine |
Kidney stones Glaucoma Use with caution in depression/anxiety |
| Neurotoxin | ||||
| Onabotulinum Toxin Type A (Botox) |
155 mg to 195 units SC or IM |
Local pain after injections Cosmetic asymmetry in the face (dropped brow etc) Neck weakness (rare) |
Chronic migraine only (15+ days of migraine symptoms per month) | Neuromuscular disease Coagulation disorders are not a strict contra-indication. |
| CGRP monoclonal antibodies (MABs) | ||||
| Eptinezumab (Vyepti) |
100 mg or 300 mg every 12 weeks (IV infusion) |
Constipation |
Frequent episodic (8-14 days/month) or chronic (15+ days per month) migraine who have failed previous preventive treatments (will not be covered by insurance as first line treatment) | Women who want to become pregnant. People with allergy to a CGRP antibody. At risk for constipation (plan for management). Uncontrolled vascular disease |
| Erenumab (Aimovig) |
70 mg or 140 mg every 28 days (injection) |
Constipation |
Frequent episodic (8-14 days/month) or chronic (15+ days per month) migraine who have failed previous preventive treatments (will not be covered by insurance as first line treatment) | Women who want to become pregnant. People with allergy to a CGRP antibody. At risk for constipation (plan for management). Uncontrolled vascular disease |
| Galcanezumab (Emgality) |
Load 240 mg |
Skin reaction at the injection site Pain in muscles and joints Allergy /hypersensitivity reaction |
Frequent episodic (8-14 days/month) or chronic (15+ days per month) migraine who have failed previous preventive treatments (will not be covered by insurance as first line treatment) | Women who want to become pregnant. People with allergy to a CGRP antibody. At risk for constipation (plan for management). Uncontrolled vascular disease |
| Fremanezumab (Ajovy) |
225 mg every 28 days or 675 mg every 12 weeks (injection) | Skin reaction at the injection site Pain in muscles and joints Allergy /hypersensitivity reaction |
Frequent episodic (8-14 days/month) or chronic (15+ days per month) migraine who have failed previous preventive treatments (will not be covered by insurance as first-line treatment) | Women who want to become pregnant. People with allergy to a CGRP antibody. At risk for constipation (plan for management). Uncontrolled vascular disease |
| Gepants | ||||
| Atogepant (Qulipta) | 10mg, 30mg, 60mg once daily | Nausea, fatigue, constipation | Episodic migraine (less than 15 days of migraine symptoms per month) | Severe hepatic impairment. Avoid during pregnancy |
| Rimegepant** (Nurtec) | 75mg every other day | Nausea, fatigue, constipation | TBD | Severe hepatic impairment. Avoid during pregnancy |
| Natural products and supplements | ||||
| Magnesium citrate or glycinate |
300 mg twice daily or once before bed | GI cramps, diarrhea | Constipation | Loose bowel movements, cramps |
| Vitamin B2 (riboflavin) |
400 mg daily | Yellow/orange urine | None | None |
| Coenzyme Q10 | 100 mg TID or 300 once daily | Stomach upset | None | None |
| Butterbur (Petadolex) |
75 mg twice daily | GI (burping) |
Petadolex is Health Canada approved. Note that some forms of butterbur may have a risk for liver toxicity. |
|
| Should NOT be first line, less frequently used, low evidence for efficacy but may be used in selected cases with significant comorbidity. | ||||
| Verapamil Isoptin |
240 mg daily | Constipation Leg edema AV block, fatigue |
Hypertension Angina |
Constipation Hypotension |
| Gabapentin Neurontin |
1200- 2400 daily (divided doses) | Drowsiness Dizziness Weight gain |
Epilepsy Neuropathic pain Insomnia |
Kidney failure (dose adjustment) |
| Venlafaxine Effexor |
150 -225 mg daily | Nausea, vomiting, dry mouth, constipation Nightmares Drowsiness |
Depression Anxiety |
Hypertension Kidney failure |
| Valproic acid | 500 to 1000 mg twice daily | Nausea, tremor, weight gain, hair loss, diarrhea, dizziness Liver toxicity Parkinsonism Teratogenicity |
Epilepsy Bipolar disease |
Women of childbearing age |
** Rimegepant is expected for approval in Canada in 2024
REFERENCES
- Pringsheim T, Davenport W, Mackie G, Worthington I, Aube M, Christie SN, et al. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012;39(2 Suppl 2):S1-59.
- Rajapakse T, Pringsheim T. Nutraceuticals in Migraine: A Summary of Existing Guidelines for Use. Headache. 2016;56(4):808-16.
- Tepper SJ. History and Review of anti-Calcitonin Gene-Related Peptide (CGRP) Therapies: From Translational Research to Treatment. Headache. 2018;58 Suppl 3:238-75.
- https://www.abbvie.ca/content/dam/abbvie-dotcom/ca/en/documents/products/QULIPTA_PM_EN.pdf<span
- Argyriou AA, Mantovani E, Mitsikostas DD, Vikelis M, Tamburin S. A systematic review with expert opinion on the role of gepants for the preventive and abortive treatment of migraine. Expert Rev Neurother. 2022;22(6):469-88.
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