Preventive medicines

Also known as prophylactic medication, taken to prevent attacks

Introduction

In the past few years the use of prophylactic or preventive drug treatments has fallen. This could be because some prophylactics have side effects such as weight gain and can take time before they start to show a beneficial effect. Also acute medication has improved for migraine. However, if you are having at least four migraine attacks per month you may wish to discuss prophylactic medication with your GP.

It could take up to three months for the preventive effect of the drug to be felt. Therefore, if the drug did not relieve your migraine attack it does not mean that the drug itself did not work but that you need to give it some time. You must avoid overusing painkillers as this can make the headaches harder to treat.

It is important to note that some preventive drugs prescribed by your GP for your migraine may be licensed for other conditions such as high blood pressure, depression or epilepsy. This could mean that the information sheet is more relevant to those conditions. If you see information in the Patient Information Sheet which you don’t understand you should discuss this further with your GP.

All preventive treatments for migraine

Drug Start dose Increment Max dose Comments
Acupuncture 10 sessions
Angiotensin Receptor Blockers/ACE inhibitors
Candesartan 2 mg/day 2 mg 8 mg BD
Lisinopril 10 mg/day 10 mg 20 mg/day
Anticonvulsants
Topiramate 25 mg/day 25 mg 100 mg BD
Sodium Valproate 200 mg BD 100 mg 1000 mg BD MHRA and NHS safety alerts*
Beta Blockers
Propranolol 10-20 mg BD 10-20 mg 120-240 mg/day
Metoprolol 25-50 mg/day 50mg BD 200 mg total daily in BD or TDS regimen
Nadolol 40 mg/day 40 mg 160 mg/day
Timolol 10 mg BD 10 mg 30 mg BD
Atenolol 50 mg/day 50 mg 200 mg/day
Calcium Channel Blockers
Flunarizine 5 mg/day 5 mg 10 mg/day Not marketed in the UK
CGRP monoclonal antibodies
Erenumab 70-140 mg monthly Max dose as per licensed indication
Fremanezumab 225 mg monthly

675 mg three-monthly

Max dose as per licensed indication
Galcanezumab 120-240 mg monthly Max dose as per licensed indication
Greater Occipital Nerve Block Local anaesthetic +/- steroids SC Not applicable if using local anaesthetic only 4 small RCT – 3 showing reduced headaches frequency over 1-4 weeks
Onabotulinumtoxin 155 IU 195 IU IM every 3 months
Neuromodulation
External Trigeminal Nerve Stimulation As per specialist recommendations
Single Transcranial Magnetic Stimulation As per specialist recommendations During aura or start of headache
Transcutaneous Vagal Nerve Stimulation As per specialist recommendations
Supplements
Co-enzyme Q10 150 mg/day
Magnesium 400 mg/day 200 mg 600 mg/day
Riboflavin 400 mg/day
Tricyclic Antidepressants
Amitriptyline 10 – 25 mg/day 10 – 25 mg 150 mg ON

(Tables taken from the British Association for the Study of Headache’s National Headache Management System for Adults 2019)

*Valproate Patient Safety Alert
In girls and women of childbearing potential, valproate should be initiated and supervised by a specialist and only prescribed when other medications have not been tolerated or have found to be ineffective. This is because of 30-40% risk of neurodevelopmental disability in unborn babies exposed to valproate (MHRA April 2017). Valproate should only be prescribed by following the MHRA guidance, including a signed contraceptive plan and signed consent form documenting discussion of the risks (see MHRA website).

Migraine is a complicated condition which varies widely between individuals. What may work for one person may not for another and your migraine management plan will be individual to you.

Doctors are unable to predict how an individual will respond to a particular treatment so this means you may need to try several different treatments until one is found that is the best at controlling your condition. Migraine is a condition for which, unfortunately, there is currently no cure.

Caution

Drugs and new treatments for migraine are changing all the time.  If you are on long term medication you should ensure that your treatment is regularly reviewed by your doctor.

Key

  • POM – Prescription only medication
  • OTC – over the counter medication
  • ® – registered
  • Enteric coated – tablets can be coated with a substance that enables them to pass through the stomach and into the intestine unchanged.
  • IV – intravenous injection
  • BNF – British National Formulary is the joint publication published by the British Medical Association and the Royal Pharmaceutical Society which is distributed to NHS doctors by the Department of Health.

For more information about a specific medicine, the electronic Medicines Compendium (eMC) website contains up to date, easily accessible information about medicines licensed for use in the UK.

 

 

Angiotensin II blockers

Action

Mode of action in migraine is unclear. They block the hormone angiotensin II. They are used in the treatment of hypertension.

Candesartan (generic name)

Candesartan is the only member of the AII antagonist group that has shown to have an effect in migraine.

Brand name Formulation type Prescription required
Amias® Tablets Yes

 

Anti-convulsants

Action

Mode of action in migraine is unclear.  They may reduce the capacity of the nerves to transmit pain signals in the brain.

Special note

The Medicines and Healthcare products Regulatory Agency (MHRA) has a toolkit to ensure female patients are informed about the risks of taking valproate medicines during pregnancy – access ‘Valproate guide for patients‘ on the Gov.uk website >

Sodium valproate (generic name)

Brand name Formulation type Prescription required
Generic form Tablets, solution. Yes
Epilim® Tablets, syrup, liquid. Yes
Epilim chrono® Tablets Yes
Episenta® Capsules Yes

Topiramate

Brand name Formulation type Prescription required
Generic form Tablets, capsules. Yes
Topamax® Tablets Yes

Gabapentin

Brand name Formulation type Prescription required
Generic form Capsules Yes
Neurotonin® Tablets, capsules. Yes

Anti-serotonergic (Anti 5-HT) drugs

Action

Serotonin (5-HT) is a chemical occurring in the body, which is thought to play a key role in migraine.  These drugs block 5-HT2 receptors to stop the effects of 5-HT.

Pizotifen (generic name)

Pizotifen also has anti-histamine properties and is related to the tricyclic antidepressants.

Brand name Formulation type Prescription required
Generic form Tablets Yes

Methysergide

Methysergide, a semi synthetic ergot alkaloid, is currently not available – read more here >

Beta-blockers

Action

These drugs have several actions and are used to treat people with high blood pressure, but are also effective in treating migraine. They should be avoided by people with asthma.

  • They reduce activity of the brain cells involved in migraine
  • They can also reduce the dilation (widening) of arteries in the body.
Generic name Brand name  Formulation type  Prescription required
Propranolol Generic form and several brands available Tablets, capsules, solutions (modified release available) Yes
Metoprolol Generic form Tablets Yes
Lopressor® Tablets Yes
Atenolol Generic form Tablets Yes
Tenormin® Tablets Yes
Nadolol Corgard® Tablets Yes
Timolol Generic form Tablets Yes
Betim® Tablets Yes

Calcitonin Gene-Related Peptide pathway monoclonal antibodies

New treatment

These are the newest preventive medicines specifically developed and licenced for the treatment of migraine.

Most of the current preventive medicines used to treat migraine have been developed for other conditions. This is therefore an exciting development for migraine sufferers.

Read more about Calcitonin Gene-Related Peptide pathway monoclonal antibodies here.

Calcium channel blockers (calcium channel antagonists)

Action

Reduces calcium entry into neurons making them less ‘excitable’.  Blocks dopamine receptors in the brain.

Flunarizine (generic name)

Flunarizine is not widely available in the UK and is usually only prescribed by a specialist.

Brand name Formulation type Prescription required
Sibelium® Tablets Yes

 

Non-steroidal anti-inflammatory drug (NSAID)

Action

NSAIDs reduce inflammation by inhibiting the production of certain chemicals in the body.

They should not be used as long-term preventives.

Naproxen (generic name)

Brand name Formulation type Prescription required
Generic form Tablets, enteric coated tablets. Yes
Naprosyn® Tablets Yes

Tricyclic antidepressants (TCAs)

Action

These drugs were previously used for depression, however, they are also effective at preventing migraine. They can be helpful in people with migraine who also have difficulty sleeping.

Tricyclic antidepressants are thought to:

  • Block the re-uptake of 5-HT and norepinephrine
  • May block 5-HT2 receptors.

The products shown are most commonly used for the prevention of migraine.

Generic name Brand name Formulation type Prescription required
Amitriptyline Generic form Tablets, oral solution. Yes
Dosulepin (Dothiepin) Generic form Capsules, tablets. Yes
Nortriptyline Generic form Tablets Yes

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