Migraine Prophylactic Tx - Drug Table
|
Migraine – Prophylactic Therapy – Drug Table |
||||||
|
Category |
Drug Name |
Common Dosing |
Maximum Daily Dose |
Cost* |
Patient Education (Comments & Warnings) |
|
|---|---|---|---|---|---|---|
|
First Line Agents |
Topiramate (Topamax) |
· 20-50mg BID · Start with 25mg daily · Can increase weekly by 25mg to 100mg in divided doses |
100mg/day |
$24.66 |
· CNS effects |
|
|
Depakote IR |
· 250-500mg BID · Increase as needed after 7 days |
1,000mg/day |
$13.00 |
· Take with food · CNS effects · Carries risk of hepatotoxicity · Do not use in pregnancy · There are reports of life-threatening pancreatitis |
||
|
Depakote ER |
· 500-1,000mg daily · Start with 500mg daily · Increase as needed after 7 days |
1,000mg/day |
$14.48 |
· Take with food · CNS effects |
||
|
Propranolol IR (Inderal) |
· 80-240mg total daily dose, divided 3-4x daily · Start IR with 80mg/day, divided every 6-8 hours · Increase by 20-40mg every 3-4 weeks |
160-240mg/day |
$32.69 |
· IR take on an empty stomach |
||
|
Propranolol ER (Inderal LA) |
· 80-240mg total daily dose, divided 3-4x daily · Start ER with 80mg/day, divided every 6-8 hours · Increase by 20-40mg every 3-4 weeks |
160-240mg/day |
$58.65 |
· ER take consistently with or without food |
||
|
Timolol |
· 10-15mg BID · Start with 10mg BID |
30mg-day |
$32.69 |
· Administer with food at the same time each day |
||
|
Metoprolol Succinate (off label) |
· 50-200mg daily · Start with 25mg daily |
400mg/day |
$24.99 |
· Can cut ER tablets in half, but do not crush or chew |
||
|
Second Line Agents |
Amitriptyline (Elavil) |
· 10-150mg daily · Increase by 10-25 mg weekly |
150mg/day |
$11.22 |
· Take at bedtime · CNS effects · May be associated with increased suicidality risk in children and adolescents |
|
|
Venlafaxine (Effexor) (off label) |
· ER 37.5-75mg |
ER 255mg |
$79.93 |
· Administer with food · Do not crush or chew ER capsules · Contents of capsule may be placed in applesauce if not chewed when swallowed · May be associated with increased suicidality risk in children and adolescents |
||
|
Atenolol (Tenormin) |
· 100mg daily · Start with 25-50mg daily |
100mg/day |
$13.63 |
|
||
|
Nadalol (Corgard) |
· 40-80mg daily · Start with 40mg daily |
240mg/day |
$116.21 |
|
||
|
Aimovig (Erenumab) |
· Erenumab: 70-140mg SC monthly |
|
$755.66 |
· For Anti-CGRP mAbs specific eligibility criteria see table below |
||
|
Ajovy (Fremanezumab) |
· Fremanezumab: 225mg SC monthly or 675mg SC quarterly |
|
$644.78 |
|||
|
Emgality (Galcanezumab) |
· Galcanezumab: 240mg SC load, then 120mg SC monthly |
|
$581.17 |
|||
|
Triptans |
Zolmitriptan (Zomig) |
· 2.5mg 2-3x/day starting 2 days prior to expected onset of menses · Continue for 5 days after onset |
Oral 5mg/dose |
$290.10 |
· Used for prevention of menstrual-associated migraines · Proper administration with nasal formulation · Can break in half to achieve smaller dose · ODT must be taken whole; place on tongue and allow to dissolve |
|
|
Frovatriptan (Frova) (off label) |
· 2.5mg 2-3x/day starting 2 days prior to expected onset of menses · Continue for 5 days after onset |
7.5mg/day |
$592.75 |
· Used for prevention of menstrual-associated migraines · Administer with fluids |
||
|
Third Line Agents |
Lisinopril |
· 5-20mg daily |
20mg/day |
$12.59 |
· May cause cough, hypotension |
|
|
Candesartan |
· 2-16mg daily |
16mg/day |
$272.25 |
· May cause hypotension |
||
|
Clonidine |
· 0.05-0.225mg daily |
0.225mg/day |
$16.94 |
· CNS effects common |
||
|
Carbamazepine |
· 600mg daily |
|
$58.41 |
· CNS effects common |
||
|
Cyproheptadine |
· 0.25-1.5mg/kg/day |
12mg divided TID |
$28.99 |
· May cause dry mouth, drowsiness, weight gain |
||
*Cost estimates are the average cost reported on GoodRx.com as of April 2021