Migraine preventives : doses, side effects and contra-indications
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 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 | 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 qd | Hypotension Dizziness | Hypertension | Hypotension |
| Topiramate Topamax | 50 to 200 mg | 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 |
| Onabotulinum Toxin Type A Botox | 155 to 195 units SC or IM | Local pain after injections Cosmetic asymmetry in the face (dropped brow etc) Neck weakness (rare) | Chronic migraine only | Neuromuscular disease Coagulation disorders are not a strict contra-indication. |
| CGRP monoclonal antibodies (MABs) | ||||
| Erenumab (Aimovig) | 70 mg or 140 mg q 28 days | Constipation 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 days | Constipation 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 months | Constipation 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 BID | 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 qd | GI upset | None | None |
| Butterbur (Petadolex) | 75 mg BID | GI (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 qd | 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 BID | Nausea, 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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