From: Aids to management of headache disorders in primary care (2nd edition)
Beta-adrenergic blockers without partial agonism: • atenolol 25-100 mg twice daily • bisoprolol 5-10 mg once daily • metoprolol 50-100 mg twice daily or modified-release 200 mg once daily • propranolol LA 80-160 mg once to twice daily | • observe general contraindications, including comorbid depression • propranolol has best evidence of efficacy, but not evidence of best efficacy • cardioselective and non-lipophyllic drugs (bisoprolol, atenolol, metoprolol) are likely to be better tolerated |
Amitriptyline 10-100 mg at night | • may be preferred when migraine coexists with tension-type headache, depression or sleep disturbance |
Topiramate 50 mg twice daily | • titrate over 4 weeks from 25 mg once daily • contraindicated in pregnancy |
Candesartan 16 mg once daily | • start at 8 mg once daily and titrate weekly • contraindicated in pregnancy |
Sodium valproate 600-1500 mg daily | • titrate upwards • avoid altogether in women of child-bearing potential (even on contraception); absolutely contraindicated in pregnancy |
Flunarizine 5-10 mg once daily | • observe general contraindications, including comorbid depression |
CGRP monoclonal antibodies (to the peptide or its receptor): • erenumab 70 or 140 mg s/c once monthly • fremanezumab 225 mg s/c once monthly or 675 mg s/c once quarterly • galcanezumab 240 mg s/c, then 120 mg s/c once monthly | • newly licensed, not yet universally available or reimbursed, usually restricted to specialist care and reserved for those failing (or not tolerating) other prophylactics • all self-administered by auto-injector • high relative cost |