Pharmacological Migraine Prophylaxis Guidelines

PHARMACOLOGICAL MIGRAINE PROPHYLAXIS GUIDELINES

Selecting a therapy:1−3 Initial selection of agents
should be based on the level of established efficacy.
Routinely evaluate patient response and utilize factors
such as comorbidities, personal considerations,
and adverse reactions to guide and individualize
therapy. Comparisons of efficacy amongst agents of
the same drug class for short-term as well as chronic
use have not been established by the evidence
currently available.

Frequent or high dosing of these medications can
lead to rebound headaches and progression to chronic
headache disorders. Initiate at the lowest possible
dose then increase to desired effect or development
of an adverse reaction. An adequate trial length is
between 2−6mos. Discontinuation via a taper is
encouraged if a patient is well-controlled after
6−12mos of therapy.

Generic Brand Notes
LEVEL A – ESTABLISHED EFFICACY*
(≥2 CLASS I TRIALS)
Anti-Epileptic Drugs (AEDs)
divalproex 
sodium
Depakote

• Routine monitoring required due to risk of
pancreatitis and hepatotoxictiy.

• Contraindicated in pregnant women for
migraine prophylaxis.

Depakote ER
topiramate Topamax  
Beta-Blockers
propranolol Inderal  
Inderal LA
timolol  
Selective 5-HT1B/1D Receptor Agonist
frovatriptan Frova

• Preferred first line agent in women of child-
bearing age for short-term prevention
of menstrually associated migraine (MAM)

LEVEL B – PROBABLY EFFECTIVE
(1 CLASS I OR 2 CLASS II STUDIES)
Nonsteroidal Antiinflammatory Drugs (NSAIDs)*
fenoprofen Nalfon

• OTC and prescription formulations can
be used

ibuprofen Advil
Motrin IB
ketoprofen ketoprofen ext-rel
naproxen Aleve
Anaprox
Anaprox DS
Naprelan
Naprosyn
Selective 5-HT1B/1D Receptor Agonist
naratriptan Amerge

• Second line alternative for MAM

zolmitriptan Zomig
Zomig-ZMT
Zomig 
Nasal 
Spray
LEVEL C – POSSIBLY EFFECTIVE
(1 CLASS II STUDY)
NSAIDs
flurbiprofen Ansaid  
mefenamic acid Ponstel  
NOTES

Not an inclusive list. Contains only those medications FDA-approved for use in the treatment of migraine, headache, and pain.

*All equally preferred

REFERENCES

Adapted from:

1. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012; 78(17):1337–1345

2. Evidence-Based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012; 78 (17): 1346–1353.

3. Silberstein SD, Holland S, Freitag F, et al. Evidence-Based guideline update: Pharmacologic treatment for episodic migraine prevention in adults: Data Supplement. Neurology. 2012; 78(17). Available at http://www.neurology.org/content/78/17/1337/suppl/DC1. Accessed May 30, 2012.

(Rev. 11/2014)

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