Preventive medications for migraine
Options to consider for preventing migraine include:
- amitriptyline (start with 10 mg and build up to 50 mg at night; off-label use)
- propranolol (start with 10 to 20mg and build up to 40 to 80mg twice daily)
- topiramate (start with 12.5mg and build up to 50 to 100 mg twice daily)
- pizotifen (start with 0.5mg and build up to 1.5 mg at night)
- verapamil, sustained release (start with 90 mg and build up to 240 mg daily; off-label use)
- candesartan (start with 4 to 8 mg and build up to 24 to 32 mg daily; off-label use).
Many more migraine preventive medications are available. For patients who fail to respond or tolerate a reasonable dose in eight to 12 weeks, consider changing to another agent or referral to a neurologist for further advice.
If oral preventive medication fails then therapies such as botulinum toxin type A and erenumab might be considered under the guidance of a neurologist or pain medicine physician. These medications have specific clinical criteria and are not suitable for all patients.
Acute treatment of migraine
Acute treatment options for migraine include:
- soluble aspirin 900 to 1000 mg or ibuprofen 400 to 600mg on a maximum of 15 days per month
- a triptan, to be used on no more than 10 days per month
- the addition of metoclopramide or prochlorperazine to acute treatments, which can have additional benefit beyond simply treating nausea
- combination therapy with aspirin plus a triptan plus metoclopramide.
Medication to treat migraine is most effective if taken early in the attack.
The characteristics of tension-type headache include:
- mild to moderate headache, lacking associated features
- lasts 30 minutes to seven days
- often described as pressure, tightness or ‘band-like’
- often does not impair the ability to undertake normal daily activities.
Preventive medications for tension-type headache
Preventive medications to consider for frequent tension-type headache include:
- amitriptyline (start with 10mg, build up to 50mg at night; off-label use)
- mirtazapine (start with 15mg, increase to 30mg as tolerated; off-label use)
- venlafaxine, modified release (start with 75mg and increase to 150mg as tolerated; off-label use).
Acute treatment of tension-type headache
Acute treatment options for tension-type headache include:
- soluble aspirin 600 to 900mg
- ibuprofen 400mg
- naproxen 500 to 750mg
- paracetamol 1g.