According to latest NICE guidelines, it’s now worth trying combination treatment (triptan + NSAID or paracetamol) as first-line, as found to be effective.
For prophylaxis, as per NICE:
- First-line: Propranolol or topiramate
- Second-line: Gabapentin (up to 1200 mg/day) or acupuncture (10 sessions over 5 – 8 weeks)
CMAJ paper has slightly different advice:
- First-line: Propranolol, amitriptyline, or nadolol (sometimes more effective than propranolol)
- Second-line: Topiramate, gabapentin, venlafaxine, lisinopril, or candesartan
- Third-line: Pizotifen (quite marked sedation/weight gain SEs)
Alternative medicine prophylactics with some evidence from RCTs:
- Acupuncture (see above)
- Magnesium citrate 600 mg od (the only prophylactic with Cat A evidence of safety in pregnancy)
- Riboflavin 400 mg od
- Coenzyme Q10 300 mg od
Note that feverfew, although commonly recommended, does not appear effective.
Menstrual-related migraine: consider zolmitriptan 2.5 mg bd or tds, or frovatriptan 2.5 mg bd, prophylactically on days when migraine is expected (but note high cost).
(Pulse on-line learning module)