Guidelines for Pharmacological Prophylaxis of Migraines
| GUIDELINES FOR PHARMACOLOGICAL PROPHYLAXIS OF MIGRAINES* | |||
|---|---|---|---|
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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 2–6 months. Discontinuation via a taper is encouraged if a patient is well-controlled after 6–12 months of therapy. |
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| Generic | Brand | Manufacturer | Notes |
| LEVEL A – ESTABLISHED EFFICACY† (≥2 CLASS I TRIALS) | |||
| ANTI-EPILEPTIC DRUGS (AEDs) | |||
| divalproex sodium | DEPAKOTE
DEPAKOTE ER |
AbbVie |
• Routine monitoring required due to risk of pancreatitis and hepatotoxictiy. |
| valproic acid | STAVZOR | Noven Therapeutics | |
| topiramate | TOPAMAX | Janssen Pharmaceuticals | |
| BETA-BLOCKERS | |||
| propranolol | INDERAL
INDERAL LA |
Akrimax | |
| timolol | Timolol | various | |
| SELECTIVE 5-HT1B/1D RECEPTOR AGONIST | |||
| frovatriptan | FROVA | Endo |
• 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 | Pedinol Pharmacal |
• OTC and prescription formulations can be used |
| ibuprofen | ADVIL | Pfizer Consumer Healthcare | |
| MOTRIN IB | McNeil Consumer & Specialty Pharmaceuticals | ||
| ketoprofen | Ketoprofen ext-rel | various | |
| naproxen | ALEVE | Bayer | |
| ANAPROX
ANAPROX DS |
Roche | ||
| NAPRELAN | Shionogi | ||
| NAPROSYN | Roche | ||
| SELECTIVE 5-HT1B/1D RECEPTOR AGONIST | |||
| naratriptan | AMERGE | GlaxoSmithKline |
• Second line alternative for MAM |
| zolmitriptan | ZOMIG
ZOMIG-ZMT ZOMIG NASAL SPRAY |
AstraZeneca | |
| LEVEL C – POSSIBLY EFFECTIVE (1 CLASS II STUDY) | |||
| NSAIDs | |||
|
flurbiprofen |
ANSAID | Pfizer | |
|
mefenamic acid |
PONSTEL | Shionogi | |
| NOTES | |||
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*Not an inclusive list. Contains only those medications FDA-approved for use in the treatment of migraine, headache, and pain. †All equally preferred Adapted by Prescribing Reference, Inc. 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. 4/2013) |
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