Migraine preventives : doses, side effects and contra-indications
Migraine Canada (MC) is a patient association, not a treating health care provider. MC cannot provide medical advice. Nevertheless, the basics of medications are public knowledge and many people ask about this type of medical information. This table is given as a general reference. Any decision to take 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 | ||||
| Amitriptyline Elavil Nortriptyline Aventyl |
10 to 50 mg at bedtime | Weight gain Drowsiness Confusion Urinary retention Constipation Dry mouth, eyes Blood pressure changes |
Insomnia Other chronic painTension type headache Note -no benefit for treating depression at lower doses |
Obesity Acute Glaucoma Prostate disease Heart block Bipolar disorder Elderly |
| Propranolol Inderal Nadolol Corgard |
80 to 160 mg daily or divided twice daily |
Fatigue Weight gain |
High blood pressure Anxiety Essential tremor |
Raynaud’s disease Low heart rate |
| Candesartan Atacand |
8 to 16 mg daily | Low blood pressure Dizziness |
High blood pressure | Low blood pressure |
| Topiramate Topamax |
50 to 200 mg daily or divided twice daily | Thinking difficulties Tingling sensation in limbs 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 injected by physician | Local pain after injections Cosmetic asymmetry in the face (dropped brow etc) Neck weakness (rare) |
Chronic migraine only | Neuromuscular disease Note – blood clotting disorders are not a strict contra-indication. |
| CGRP monoclonal antibodies (MABs) | ||||
| Erenumab (Aimovig) |
70 mg or 140 mg every 28 days |
Constipation ** Other reactions not seen in studies but reported in practice: weight gain, hair loss, nightmares, anxiety, increase in headache |
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 get pregnant People with allergy to a CGRP antibody At risk for constipation (plan for management) Uncontrolled vascular disease |
| Galcanezumab (Emgality) |
First dose:240 mg then 120 mg every 28 days | 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 by insurance as first line treatment) | Women who want to get pregnant People with allergy to a CGRP antibody Uncontrolled vascular disease |
| Fremanezumab (Ajovy) |
225 mg every 28 days or 675 mg every 3 months | 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 by insurance as first-line treatment) | Women who want to get pregnant People with an allergy to a CGRP antibody Uncontrolled vascular disease |
| Natural products and supplements | ||||
| Magnesium citrate or glycinate |
300 mg BID | Stomach cramps, diarrhea | Constipation | Loose bowel movements, cramps |
| Vitamin B2 (riboflavin) |
400 mg daily | Yellow/orange urine | None | None |
| Coenzyme Q10 | 300 mg (divided once or three times daily) | Stomach upset | None | None |
| Butterbur (Petadolex) |
75 mg twice daily | (burping) | Warning – Some formulations may contain toxic chemicals that can cause liver damage. Only formulations that have been proven to be safe because these toxic chemicals have been removed should be used (for example Petadolex). |
None |
| 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 swelling Heart block, fatigue |
High blood pressure Angina |
Constipation Low blood pressure |
| Gabapentin Neurontin |
1200- 2400 daily (divided doses) | Drowsiness Dizziness Weight gain |
Epilepsy Nerve pain Insomnia |
Kidney failure (dose adjustment) |
| Venlafaxine Effexor |
150 -225 mg daily | Nausea, vomiting, dry mouth, constipation Nightmares Drowsiness |
Depression Anxiety |
High blood pressure 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 |
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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