Migraine Prophylaxis Management

Indications and First-Line Prophylactic Medications

The American Academy of Family Physicians recommends prophylactic therapy for patients with two or more migraine attacks per month with disability lasting 3 or more days per month 1, 3
The American Academy of Family Physicians suggests considering prophylactic therapy for patients with contraindication to or failure of acute treatments 3
The American Academy of Family Physicians recommends considering prophylactic therapy for patients using abortive medication more than twice per week 3, 4
Propranolol (80-240 mg/day) and timolol (20-30 mg/day) have good evidence for efficacy as first-line prophylactic medications 3, 5
Amitriptyline (30-150 mg/day) shows good efficacy as a first-line prophylactic medication 1, 3
Divalproex sodium (500-1500 mg/day) and sodium valproate (800-1500 mg/day) have good evidence for efficacy as first-line prophylactic medications 1, 3

The American College of Physicians recommends starting with a low dose and titrating slowly upward until clinical benefits are achieved or side effects limit further increases 2
The American College of Physicians suggests allowing an adequate trial period of 2-3 months before determining efficacy 2
The American College of Physicians recommends monitoring for medication overuse, which can interfere with prophylactic treatment 2
The American Academy of Neurology recommends using headache diaries to track attack frequency, severity, duration, resulting disability, response to treatment, and adverse effects 1
Patient education about migraine as a disease and principles of management is essential for treatment success, according to the American Academy of Neurology 7

The American Headache Society recommends avoiding medications that may interfere with prophylactic treatment, such as overused acute medications like ergotamine 1
The American Headache Society suggests considering targeted prophylaxis around menstruation for women with menstruation-related migraine 7
Failing to recognize medication overuse headache can occur with frequent use of acute medications, according to the American Academy of Neurology 4
Inadequate duration of prophylactic trial can lead to poor efficacy, according to the American College of Physicians 2