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Table 9 Migraine prophylactic drugs with evidence of efficacy in adults (drugs are listed in a suggested order of use; within classes [beta blockers and CGRP monoclonal antibodies], they are listed alphabetically)

From: Aids to management of headache disorders in primary care (2nd edition)

Beta-adrenergic blockers without partial agonism:
 • atenolol 25-100 mg twice daily
 • bisoprolol 5-10 mg once daily
 • metoprolol 50-100 mg twice daily or modified-release 200 mg once daily
 • propranolol LA 80-160 mg once to twice daily
• observe general contraindications, including comorbid depression
• propranolol has best evidence of efficacy, but not evidence of best efficacy
• cardioselective and non-lipophyllic drugs (bisoprolol, atenolol, metoprolol) are likely to be better tolerated
Amitriptyline 10-100 mg at night • may be preferred when migraine coexists with tension-type headache, depression or sleep disturbance
Topiramate 50 mg twice daily • titrate over 4 weeks from 25 mg once daily
• contraindicated in pregnancy
Candesartan 16 mg once daily • start at 8 mg once daily and titrate weekly
• contraindicated in pregnancy
Sodium valproate 600-1500 mg daily • titrate upwards
avoid altogether in women of child-bearing potential (even on contraception); absolutely contraindicated in pregnancy
Flunarizine 5-10 mg once daily • observe general contraindications, including comorbid depression
CGRP monoclonal antibodies (to the peptide or its receptor):
 • erenumab 70 or 140 mg s/c once monthly
 • fremanezumab 225 mg s/c once monthly or 675 mg s/c once quarterly
 • galcanezumab 240 mg s/c, then 120 mg s/c once monthly
• newly licensed, not yet universally available or reimbursed, usually restricted to specialist care and reserved for those failing (or not tolerating) other prophylactics
• all self-administered by auto-injector
• high relative cost