Table 7 Drugs for the preventive treatment of migraine with a level of recommendation I and II

Beta-blockers

 Propranolol

80–240

I

Useful in patients with hypertension, anxiety and panic disorders. It can exacerbate depression. Do not use with ergotamine. Increase doses gradually. Particularly useful in patients with essential tremor. Most frequent adverse events are fatigue, mood disorders, nightmares. Other side effects are bradicardia, orthostatic hypotension, impotence, hallucinations, weight gain

 Metoprolol

50–200

I

Same indications and side effects as for propranolol, excluding essential tremor

 Atenolol

100

I

Same indications and side effects as for propranolol, excluding essential tremor

 Bisoprolol

5–10

II

Same indications and side effects as for propranolol, excluding essential tremor

 Nadolol

40–240

II

Calcium channel blockers

 Flunarizine

5–10

I

Use administration schedules with periodic suspensions (i.e. 5 days/week or 3 weeks/month), to avoid the accumulation of the drug

Most frequent side effects are weight gain, sedation and depression. Extrapyramidal symptoms may be observed in elderly patients. The recommended dose to reduce adverse events is 5 mg

 Cinnarizine

75–150

II

Most frequent side effects are weight gain and drowsiness

Antidepressants tricyclic

 Amitriptyline

10–75

I

Dosages tested in clinical trials, the majority of them dated, are in general higher than those usually used in clinical practice for prophylactic treatment of migraine

A progressive increase in doses is recommended until maintenance doses are reached in order to reduce adverse events

Most frequent side effects are drowsiness, weight gain and anticholinergic symptoms. Particularly useful in patients with depression, concurrent migraine and tension-type headache. Higher doses should be used in patients with comorbid depression

Antiepileptic drugs

 Sodium valproate

500–1,500

I

Controlled release formulations are available with a better tolerability profile. Recommended for patients with prolonged or atypical migraine aura. Not recommended in patients with liver disease and haemorrhagic diathesis. A progressive increase in doses is recommended. Frequent adverse events include nausea, asthenia, somnolence. Other side effects include weight gain, hair loss and tremor. Teratogenic potential

 Topiramate

50–100

I

Gradual increase of dosage is recommended. Frequent, not serious adverse events include paresthesiae, memory and concentration disturbances, nausea, weight loss and drowsiness. Rare serious adverse events include kidney stones, narrow-angle glaucoma

 Gabapentin

900–2,400

II

Recommended for elderly patients. Well tolerated

5HT-antagonists

 Pizotifen

1.5

II

Frequent adverse events include weight gain and somnolence

Other drugs

 Dihydroergotamine

10

II

Do not use within 6 h after triptan administration. Useful for intermittent or short-term prophylaxis. Withdrawal could be associated with rebound headache

 Dihydroergocriptine

20

II

Mild side effects. Withdrawal could be associated with rebound headache

 Onabotulinum toxin type A

155–195 U^a

IV (episodic migraine)

I (chronic migraine)

The majority of controlled studies have not provided conclusive results in episodic migraine

It is effective in chronic migraine. Costs are comparable to topiramate 100 mg for a period of treatment of 3 months and lower than topiramate for a period of 4 months