Migraine Canada is a patient association, not a treating health care provider. MC cannot provide medical advice. Nevertheless, basics on medications are public knowledge and many people ask about this type of medical information. This table is given as general reference. Any decision to take a medication should be discussed with a health care provider. 

Table : Migraine Preventives 


Usual doseMain side effectsChoose for patients withAvoid in patients with
Frequently used (brand name)
Amitriptyline
Elavil

Nortriptyline
Aventyl
10 to 50 mg at bedtimeWeight gain
Drowsiness
Confusion
Urinary retention
Constipation
Dry mouth, eyes
Orthostatic hypotension
Insomnia
Other pain
Tension type headache* no effect on depression at lower doses
Overweight
Glaucoma
Prostate disease
Heart block
Bipolar disorder
Elderly
Propranolol
Inderal

Nadolol
Corgard
80 to 160 mg qd (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 qdHypotension
Dizziness
HypertensionHypotension
Topiramate
Topamax
50 to 200 mgCognitive 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
Onabotulinum Toxin Type A
Botox
155 to 195 units SC or IMLocal pain after injections
Cosmetic asymmetry in the face (dropped brow etc)
Neck weakness (rare)
Chronic migraine onlyNeuromuscular disease
Coagulation disorders are not a strict contra-indication.
CGRP monoclonal antibodies (MABs)
Erenumab
(Aimovig)
70 mg or 140 mg q 28 daysConstipation
Skin reaction at the injection site
Pain in muscles and joints
Allergy /hypersensitivity reaction
** Other reactions not seen in studies but reported in practice: weight gain, hair loss, nightmares, anxiety, increase of the headache
Frequent episodic (8-14 days/month) or chronic (15+ days per month) migraine who have failed previous preventive treatments (will not be covered as first line treatment)
Women who want to get pregnant
People with allergy to a CGRP antibody
At risk for constipation (plan for management) Uncontrolled vascular disease
Galcanezumab
(Emgality)
Load 240 mg120 mg q 28 daysConstipation
Skin reaction at the injection site
Pain in muscles and joints
Allergy /hypersensitivity reaction
** Other reactions not seen in studies but reported in practice: weight gain, hair loss, nightmares, anxiety, increase of the headache
Frequent episodic (8-14 days/month) or chronic (15+ days per month) migraine who have failed previous preventive treatments (will not be covered as first line treatment)
Women who want to get pregnant
People with allergy to a CGRP antibody
At risk for constipation (plan for management) Uncontrolled vascular disease
Fremanezumab
(Ajovy)
225 mg q 28 days or 675 mg q 3 monthsConstipation
Skin reaction at the injection site
Pain in muscles and joints
Allergy /hypersensitivity reaction
** Other reactions not seen in studies but reported in practice: weight gain, hair loss, nightmares, anxiety, increase of the headache
Frequent episodic (8-14 days/month) or chronic (15+ days per month) migraine who have failed previous preventive treatments (will not be covered as first line treatment)
Women who want to get pregnant
People with allergy to a CGRP antibody
At risk for constipation (plan for management) Uncontrolled vascular disease
Natural products and supplements
Magnesium
citrate or glycinate
300 mg BIDGI cramps, diarrheaConstipationLoose bowel movements, cramps
Vitamin B2
(riboflavin)
400 mg dailyYellow/orange urineNoneNone
Coenzyme Q10100 mg TID or 300 qdGI upsetNoneNone
Butterbur
(Petadolex)
75 mg BIDGI (burping)AVOID
Liver toxicity concerns

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 qdConstipation
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 dailyNausea, vomiting, dry mouth, constipation
Nightmares
Drowsiness
Depression
Anxiety
Hypertension
Kidney failure
Valproic acid500 to 1000 mg BIDNausea, tremor, weight gain, hair loss, diarrhea, dizziness
Liver toxicity
Parkinsonism
Teratogenicity
Epilepsy
Bipolar disease
Women of childbearing age

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.

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