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Table 10 Drugs used by specialists in chronic migraine prophylaxis

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

Topiramate, 50 mg or more twice daily
Onabotulinum toxin A, 155-195 units by multisite injection • not licensed for chronic migraine in some countries, or
• not reimbursed, and/or
• regulators require prior failure of two or more of the drugs used in prophylaxis of episodic migraine
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