Preventives – recommended doses for migraine

Please note the recommended doses below are for adults. Not all of these treatments are licensed for use in children, and doses for children may differ. Talk to your GP or specialist for more information on recommended migraine treatments for children.

Angiotensin Receptor Blockers/ACE inhibitors

Drug	Starting dose	Increment	Maximum dose
Candesartan	2 mg/day	2 mg	8 mg BD
Lisinopril	10 mg/day	10 mg/day	20 mg/day

Anticonvulsants

Drug	Starting dose	Increment	Maximum dose	Comments
Topiramate	25 mg/day	25 mg	100 mg BD	Safety alert *
Sodium Valproate	200 mg BD	100 mg	1000 mg BD	Safety alert *

Beta Blockers

Drug	Starting dose	Increment	Maximum dose
Propranolol	10-20 mg BD	10-20 mg	120-240 mg/day
Metoprolol	25-50 mg/day	50mg BD	200 mg total daily in BD or TDS regimen
Nadolol	40 mg/day	40 mg	160 mg/day
Timolol	10 mg BD	10 mg	30 mg BD
Atenolol	50 mg/day	50 mg	200 mg/day

CGRP monoclonal antibodies

Drug	Starting dose	Maximum dose
Erenumab	70-140 mg monthly	Max dose as per licensed indication
Fremanezumab	225 mg monthly 675 mg three-monthly	Max dose as per licensed indication
Galcanezumab	120-240 mg monthly	Max dose as per licensed indication

Greater Occipital Nerve Block

Drug	Starting dose	Maximum dose	Comments
Greater Occipital Nerve Block	Local anaesthetic +/- steroids SC	Not applicable if using local anaesthetic only	4 small RCT – 3 showing reduced headaches frequency over 1-4 weeks
Greater Occipital Nerve Block	155 IU	195 IU	SC every 12 weeks

Serotonin antagonist

Drug	Starting dose	Increment	Maximum dose
Pizotifen	0.5 mg	0.5-1 mg	4.5 mg/day (divided into 3 doses)

Supplements

Drug	Starting dose	Increment	Maximum dose
Co-enzyme Q10	150 mg/day
Magnesium	400 mg/day	200 mg	600 mg/day
Riboflavin	400 mg/day

Tricyclic antidepressants

Drug	Starting dose	Increment	Maximum dose
Amitriptyline	10 – 25 mg	10 – 25 mg/day	150 mg ON

Safety alert *: Topiramate and sodium valproate can cause harm to a developing baby during pregnancy. If you are a woman or girl of childbearing age, you will only be prescribed them if you have had a negative pregnancy test, you are on suitable contraception to prevent pregnancy, and you have signed a consent form to show that you have discussed the risks.

(Tables taken from the British Association for the Study of Headache’s National Headache Management System for Adults 2019)