Medical Treatment Guidelines for Preventive Treatment of Migraine

The Treatment Guideline Subcommittee of the Taiwan Headache Society evaluated the medications currently used for migraine prevention in Taiwan. We assessed the results of new published drug trials, information from medical database and referred to the latest guidelines published. After comprehensive discussion, we proposed Taiwanese consensus about the preventive treatment for migraine including recommendation levels, strength of evidences, and related prescription information regarding dosage and adverse effects. This guideline is updated from earlier version published in 2008. Migraine preventive medications currently available in Taiwan can be categorized into ß-blockers, antidepressants, calcium channel blockers, anticonvulsants, nonsteroid anti-inflammatory drugs, OnabotulinumtoxinA and miscellaneous medications. Propranolol has the best level of evidence and fewer side-effects, and is recommended as the first-line medication for episodic migraine prevention. Valproic acid, topiramate, flunarizine and amitriptyline are suggested as the second-line medications. The rest medications are used when the above medications fail. OnabotulinumtoxinA and topiramate are recommended for chronic migraine prevention. Those other medications used for episodic migraine could also be used as a second-line option. It is not recommended to use migraine preventive medication during pregnancy or lactation. For those women with menstrual migraine, nonsteroid anti-inflammatory drugs and triptans can be used for prevention during the menstrual period. The levels of evidences for migraine preventive medications in children/adolescents and elderly are low. The preventive medications should follow the "start low and go slow" doctrine to reach an effective dosage. This can prevent adverse events and improve tolerance. The efficacy of preventive medications cannot be evaluated until 3 to 4 weeks after treatment. If the improvement of migraine maintains for 6 months, physicians can gradually taper the medications. Physicians should notify the patients not to overuse acute medications during migraine prevention treatment.