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
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
Erenumab
(Aimovig)
70 mg or 140 mg every 28 days (injection)

Constipation
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
Galcanezumab
(Emgality)

Load 240 mg
120 mg every 28 days
(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
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) Some forms may have risks of liver toxicity, Petadolex is Health Canada approved
 
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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