Migraine Prophylaxis with Flunarizine and Propranolol

Introduction to Migraine Prophylaxis

The American College of Physicians recommends trying beta-blockers first, then moving to other agents if inadequate response occurs 1

Start with propranolol (80-160 mg daily) as the initial preventive agent, classified as first-line therapy with the strongest evidence base 2, 1, 3, 4
Propranolol is particularly appropriate for patients with comorbid hypertension or anxiety 1
Dose range for propranolol: 80-240 mg/day in long-acting formulations 5, 2

Switch to flunarizine (5-10 mg daily) if propranolol fails or is not tolerated, designated as second-line therapy in current guidelines 5, 2
Standard dosing for flunarizine: 5-10 mg once daily 5, 2

Flunarizine is absolutely contraindicated in patients with Parkinsonism or depression 5, 2
Flunarizine can cause extrapyramidal symptoms, particularly in elderly patients 3
Propranolol is contraindicated in patients with asthma, heart failure, or significant bradycardia 2, 1

Evaluate treatment effectiveness at 2-3 months using headache calendars to track attack frequency, severity, and disability 5, 2
Define treatment success as ≥50% reduction in attack frequency 5, 2

Avoid combining propranolol and flunarizine without first trying adequate trials of each as monotherapy 5, 2, 1
Do not declare treatment failure before allowing 2-3 months for clinical benefit to manifest 5, 3, 4

The American Academy of Neurology recommends beta-blockers, anticonvulsants, and candesartan as first-line preventative medications for migraine treatment, with strong evidence supporting their efficacy in reducing migraine frequency and severity 6
Candesartan has sufficient evidence to be considered a first-line preventative treatment 6

Flunarizine is recommended as a second-line treatment after beta-blockers, topiramate, and candesartan, with a recommended dose of 10mg/day 7
Amitriptyline has evidence supporting its use, particularly when combined with cognitive behavioral therapy 8, 9, 10

When prescribing topiramate or valproate to women of childbearing potential, discuss teratogenic effects and advise patients to use effective birth control methods and take folate 8, 9, 10
Flunarizine's most common adverse effects include sedation, weight gain, and abdominal pain, with clinical benefits taking 2-3 months to manifest 7

Consider preventive treatments in patients with frequent or disabling headaches or medication overuse 8, 9, 10
Start with first-line agents (beta-blockers, topiramate, divalproex sodium, or candesartan) based on comorbidities and potential side effects 6
If first-line treatments are ineffective or poorly tolerated, move to second-line options such as flunarizine or amitriptyline 7
Allow adequate trial periods (2-3 months) before determining efficacy of preventive medications 7
Discuss with patients that placebo was as effective as studied medications in many trials, particularly in children and adolescents 8, 9, 10