Preventative Headache Medications
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This resource serves as a comprehensive list of first and second-line headache prevention medications.
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You'll also find tools that you can download and save, like a prescribing medication flow chart to help make medication decisions.
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Consider cutting/pasting dosing instructions similar to how you might use a dotphrase or use this information to create your own dotphrase.
Medication Flow Chart
This flow chart is designed to guide you in making the best decision to help your patients prevent future headaches. It provides information like how to know when a patient is ready to try preventative medications, drugs to avoid for relative and absolute contraindications, and how to pick the most appropriate and patient-specific medication.
1st Line Anti-Hypertensives
Metoprolol & Propanolol serve as beta-blockers. All three medications can also be used to treat hypertension.
Drug | Dose | Contraindications | Warnings |
|---|---|---|---|
Propranolol
(β-nonselective)
| Initial: 20 mg BID. Goal: 40-160 mg/day. Titrate every 1-2 weeks until benefit or side effects. Monitor HR for bradycardia. No dose adjustment for CKD. | Asthma, bradycardia, sick sinus syndrome, heart block, decompensated HF. | PVD or Raynaud’s, bradyarrhythmias, bronchospasm, CNS effects, masking of hypoglycemia.
|
Metoprolol (β1 selective) | Initial: 25 mg daily. Goal: titrate every 1-2 weeks until benefit or side effects (200 mg max total daily dose).
Escalate dose based on HR and monitor for bradycardia.
No CKD dose adjustment.
| 2nd or 3rd degree AV block (except with pacemaker).
| Masks symptoms of hypoglycemia and hyperthyroidism, may worsen PVD. |
Candesartan | Initial: 4-8 mg daily. Goal: 4-8 mg daily (max daily dose 16 mg). | Pregnancy | Hypotension or hyperkalemia. |
1st Line Preventative Treatments
1st Line Anti-Epileptics
These medications are often favorable for headache patients who are overweight.
Drug | Dose | Contraindications | Warnings |
|---|---|---|---|
Divalproex sodium (Depakote) | Initial: 500 mg daily (ER). Goal: titrate every 3+ days by 250 mg up to 1 g/d in 1-2 divided doses. No CKD dose adjustment, but clearance may be reduced in CrCl < 10.
| Women of childbearing age w/o contraception, known mitochondrial disorders. | May stimulate viral replication, hematologic effects, hepatotoxicity, SJS/TEN*, DRESS**, suicidal ideation.
|
Topiramate | Initial: 25 mg daily. Goal: titrate every 1+wk up to 100 mg daily (1-2 divided doses). No CKD dose adjustment, however use 50% of indicated dose in CrCl < 70 and titrate more slowly.
| Recent alcohol use (Trokendi ER only), pregnancy (teratogenic), hx of kidney stones, cognitive impairment, acute congestive glaucoma.
| Nephrolithiasis, metabolic acidosis, ocular effects, suicidal ideation/tendencies, weight loss/anorexia. |
*Stevens-Johnson syndrome/toxic epidermal necrolysis.
**Drug reaction with eosinophilia and systemic symptoms.
1st Line CGRP Inhibitors
Many insurances require step therapy to be met before covering CGRP inhibitor medications for migraine. This typically includes a failed trial or side effects to at least 2 classes of migraine medications (i.e., a trial of at least one antihypertensive, antiepileptic, or antidepressant medication for at least 3 months). Galcanezumab (Emgality) is traditionally the easiest to get approved for if the patient has commercial insurance. Fremanezumab (Ajovy) and erenumab (Aimovig) are traditionally the easiest to get pre-approved for patients with Medicaid.
Drug | Dose | Contraindications |
|---|---|---|
Rimegepant (Nurtec) | 75 mg once every other day. CrCl < 15: AVOID.
| Pregnancy or Lactation |
Atogepant (Qulipta) | 10-60 mg once daily based on risk of side effects (nausea, constipation, loss of appetite). CrCl < 30: Max total daily dose 10 mg. | Pregnancy or Lactation |
Galcanezumab (Emgality) | Loading Dose - 120 mg X2, Maintenance Dose - 120 mg every 30 days. | Pregnancy or Lactation |
Fremanezumab (Ajovy) | 225 mg/1.5 ml SUBQ every 30 days or 675 mg/4.5 ml SUBQ every 90 days. | Pregnancy or Lactation |
Erenumab (Aimovig) | 70-140 mg SUBQ every 30 days. | Pregnancy or Lactation |
2nd Line PreventativeTreatments
2nd Line Anti-Hypertensives
These medications can also be used to treat hypertension.
Drug | Dose | Contraindications | Warnings |
|---|---|---|---|
Nadolol
(β-nonselective)
| Initial: 80 mg daily.
Goal: 80-240 mg/day. Titrate every 1-2 weeks until benefit or side effects.
Monitor HR for bradycardia.
CrCl 31-50: extend dose to every 24-36 hours;
CrCl 10-30: extend dose to every 24-48 hours;
CrCl<10: extend dose to every 40-60 hours.
| Asthma, bradycardia, sick sinus syndrome, heart block, decompensated HF. | PVD or Raynaud’s, bradyarrhythmias, bronchospasm, CNS effects, masking of hypoglycemia.
|
Atenolol
(β1 selective) | Initial: 25 mg daily.
Goal: titrate every 1-2 weeks until benefit or side effects (200 mg max total daily dose).
Escalate dose based on HR and monitor for bradycardia.
CrCl 10-30: 50 mg max total daily dose;
CrCl<10: 25 mg max total daily dose.
| 2nd or 3rd degree AV block (except with pacemaker). | Masks symptoms of hypoglycemia and hyperthyroidism, may worsen PVD. |
Lisinopril | Initial: 10 mg once daily; may increase dose after 1 week to 20 mg daily based on response and tolerability. CrCl 10-30mL/min: initial 2.5 mg once daily and titrate slowly. CrCl <10mL/min: avoid use. | Women of childbearing age, Pregnancy or lactation, history of angioedema. | Acute kidney injury, hyperkalemia, cough. |
2nd Line Anti-Depressants
These medications can also be used to treat anxiety and depression.
Drug | Dose | Contraindications | Warnings |
|---|---|---|---|
Venlafaxine (Effexor) | Initial: 37.5 mg ER daily. Goal: titrate q 1 wk to targets of 75-150 mg daily. No CKD dose adjustment, but titrate cautiously in CrCl <30.
| None | Mania/hypomania, bleeding risk, BP elevations, fragility fracture, hepatotoxicity, ocular effects, sexual dysfunction, additive serotonin syndrome risk. |
Amitriptyline (Elavil) | Initial: 10-25 mg nightly (consider lower starting doses for underweight or elderly). Goal: titrate every 1-2 weeks until benefit or side effects (150 mg max total daily dose). | History of suicidal ideation. | Cardiac conduction abnormalities, ocular effects, orthostatic hypotension, anticholinergic effects, additive serotonin syndrome risk.
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2nd Line NMDA Antagonists
These medications can also be used to treat Alzheimer's disease, vascular dementia, Parkinson's disease, memory loss, brain damage, benzodiazepine withdrawal, traumatic brain injury, and stroke.
Drug | Dose | Warnings |
|---|---|---|
Memantine | Initial: 5 mg twice daily. Goal: 10 mg twice daily. CrCl 30-50: 5 mg once daily and increase if needed as tolerated by 5 mg increments no more frequently than weekly. CrCl<30: 5 mg once daily and increase every 1+ week to a max dose of 5 mg twice daily.
| Neuropsychiatric effects (confusion, dizziness, sleep disturbance, delusion, etc).
|
Preventive Medications List PDF
Consider downloading and saving the following PDF for quick access to this list of first-line and second-line preventive medications.
Non-Pharmacologic Options
Migraine Treatment Devices
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Some patients might be interested in trying a migraine device. Some devices like Relivion, Gammacore, eNeura TMS, and Nerivio, require a prescription. Other devices, such as Cefaly and HeadaTerm 2, are available to patients without a prescription.
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Cefaly and HeadaTerm 2 are devices that are FDA-approved for migraine treatment.
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Both devices are non-invasive and non-pharmacologic.
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These devices can be used in conjunction with headache medications or alone.
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These devices do not require a prescription and patients can purchase using their Health Savings Account (HSA) or Flexible Spending Account (FSA).
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The devices use an adhesive to temporarily stick to your forehead and deliver electric impulses to the forehead as an approach to reducing headaches.
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Patients can use these devices for both acute and preventative treatment.
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Trying Cefaly
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Cefaly typically costs about $400*, which isn't accessible for everyone.
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CEFALY.com does offer a full refund to patients within 90 days of purchase.* It's safest to confirm this return policy with the vendor before purchasing.
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Trying HeadaTerm 2
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HeadaTerm 2 typically costs about $100* and has a 30 day money back guarantee* if patients purchase from Emeterm.com
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