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Prophylactic treatment
bulletMay be needed if
bulletAttacks are severe enough to impair quality of life or
bullet3 or more severe attacks per month that fail to respond adequately to abortive or symptomatic therapy.
bulletAll effective prophylactic agents decrease the frequency of migraine by 40%, compared with placebo.
bulletFew controlled clinical trials demonstrate differences between two groups of drugs.
bulletBeta Blockers:
bulletAtenolol 50-150 mg/d
bulletMetoprolol 100-200 mg/d
bulletNadolol 20-160 mg/d
bulletPropranolol 80-240 mg/d
bulletSide effects: Fatigue, bronchospasm, bradycardia, hypotension, congestive heart failure, depression, impotence, sleep disturbance
bulletTricyclic analgesics
bulletAmitriptyline 10-150 mg every night
bulletNortriptyline 10-150 mg every night
bulletDry mouth, constipation, weight gain, drowsiness, reduced seizure threshold, cardiovascular effects
bulletAnticonvulsant
bulletValproic acid 500-1500 mg/d
bulletSide effects: Nausea, tremor, weight gain, alopecia, increased liver enzyme levels
bulletTopiramate 100-200 mg per day
bulletSide effects: paresthesia, cognitive impairment, weight loss
bulletNSAID
bulletNaproxen sodium: 550 mg bid, use < 1 week per month
bulletProphylaxis for perimenstrual migraine.
bulletCalcium-channel blockers
bulletVerapamil 240-320 mg/d
bulletSerotonin receptor antagonists: consider as a third line drug
bulletMethysergide 2 mg every night, gradually increased to tid,  maximum 8 mg/d if needed, usual dose 4-8 mg/d.
bulletShould be given for 6 months, with a 1-month interruption before starting the drug again. It should be tapered off gradually over 1 week to avoid rebound headache.
bulletRetroperitoneal, cardiac and pulmonary fibrosis.

 

Medication Formulation, Usual dose Note
Nonspecific beta blocker
Propranolol (Inderal,
Inderal LA)		 tab: 10, 20, 40, 80 mg,
long acting: 60, 80, 120, 160 mg
dose: 40 - 240 mg/day
Nadolol tab 40 mg
dose: 40-80 mg /day, take QD
Timolol
(Blocadren)		 tab: 5,10,20 mg
dose: 10-40 mg/day, take bid
Selective beta 1 blocker at low dose
Atenolol
(Tenormin)		 tab: 25, 50, 100 mg
dose: 50-100 mg/day
Metoprolol (Lopressor) tab:50, 100 mg
dose: 50-100 mg/day
Tricyclic antidepressant
Amitriptyline (Elavil) tab: 10, 25, 50, 75, 100, 150 mg
dose: 10-150 mg/day, take hs		 weight gain, anticholinergic effect, sedating
Doxepin (Sinequan)
Imipramine (Tofranil)
Nortriptyline (Pamelor) tab/cap: 10, 25, 50, 75, 100, 150 mg
dose: 25 - 150 mg/day		 less sedating & anticholinergic effect
Desipramine (Norpramine)
Tricyclic antihistamine
Cyproheptadine (Periactin) tab 4 mg, syrup 2mg/5ml
dose: 12-24 mg /day, tid or qid
Calcium Channel Blocker
Verapamil (Calan, Calan SR) Formulations: tab 40, 80, 120. SR: 180, 240 mg
Dose: 120-240 mg/day, BID for SR
May cause constipation, leg edema.
NSAID may cause ulcer, gastritis,  renal disease
Naproxen
(Naprosyn, EC-Naprosyn)		 tab:  250, 375, 500 mg
EC Naprosyn: 375, 500 mg
dose: 250- 500 mg bid pc
Naproxen Sodium (Aleve, Anaprox, Anaprox DS) Alleve: 220 mg
Anaprox: 275 mg
Anaprox DS: 550 mg
Naprosyn controlled release
(Naprelan)		 tab: 412.5, 550 mg (equivalent to 375, 500 mg Naproxen)
Antiserotonin
Methysergide (Sansert)
bulletTab 2 mg
bulletDose: 2 mg bid to qid
bulletMay cause fibrosis with prolonged use, need drug holiday of 4 wk every 6 months.
bulletTaper dose to avoid rebound.
bulletSide effects: muscle cramps, nausea, diarrhea.
GABA agonist
Valproic acid (Depakote, Depakene)
bulletAvailable in 250, 500 mg
bulletUsual dose: 500-1500 mg per day
bulletMay cause weight gain, tremor, hair loss.

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