4.7.4.2 Migraine prophylaxis

ChoiceDrugDosage
1st choicePropranolol tablets 10mg, 40mg, 80mg, 160mg

Propranolol m/r capsules 80mg, 160mg
Dose:
Initially, 80mg daily (either 40mg twice a day or 80mg modified-release once a day). The dose may be increased to 160mg daily, and subsequently to 240mg daily if necessary (either in divided doses or as a single modified release dose)
2nd choiceTopiramate tablets 25mg, 50mg, 100mgDose:
Initially 25mg at night for 1 week then increase in steps of 25mg at weekly intervals based on clinical response; usual dose 50-100mg daily in 2 divided doses; max 200mg daily
(NB withdraw topiramate gradually)

Prescribing Notes

  • Refer to NICE Clinical Knowledge Summaries Migraine for more comprehensive information including further preventative treatment choices.
  • The aim of preventive treatment is to reduce the frequency, severity and duration of attacks and avoid medication-overuse headache (MOH).
  • Consider preventive treatment if:
    • migraine attacks are causing frequent disability (e.g. two or more attacks per month that produce disability lasting for 3 days or more)
    • the person is at risk of MOH due to frequent use of acute drugs
    • standard analgesia and triptans are contraindicated or ineffective
  • It is essential to rule out MOH before preventive treatment is initiated. If MOH is suspected then the appropriate management is drug withdrawal rather than prevention.
  • Propranolol is suitable for people with coexisting hypertension or anxiety. It is not suitable for people with asthma, COPD, peripheral vascular disease or uncontrolled heart failure.
  • Advise women and girls of childbearing potential that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraception. Ensure suitable contraception is offered.
  • If both topiramate and propranolol are ineffective (after two months of therapy at the target dose) or are unsuitable, refer to NICE CKS for information on other drug treatment options. If there is no benefit with an adequate trial of 3 prophylactic medicines and withdrawal of overused medication, consider referral to headache services for further management.
  • Pizotifen and clonidine have been widely used for many years but with little clinical trials evidence of efficacy. They should now be superseded.
  • Prophylaxis should be given for 3-6 months, then consideration given to gradual withdrawal if there has been a good response (or if response is poor).

Cautions

  • Topiramate lowers serum bicarbonate levels, with the potential to cause metabolic acidosis. Monitor serum bicarbonate levels after 2 weeks of therapy and every 3 months in people with conditions which put them at increased risk of metabolic acidosis e.g. renal disease, severe respiratory disorders, diarrhoea, surgery, ketogenic diet, certain drugs.
  • Topiramate has been associated with acute myopia with secondary angle-closure glaucoma, typically occurring within 1 month of starting treatment. Seek specialist advice and stop topiramate as rapidly as feasible.