Recommended doses for migraine preventive treatment

Angiotensin Receptor Blockers/ACE inhibitors

DrugStarting doseIncrementMaximum dose
Candesartan2 mg/day2 mg8 mg BD
Lisinopril10 mg/day10 mg/day20 mg/day

Anticonvulsants

DrugStarting doseIncrementMaximum doseComments
Topiramate25 mg/day25 mg100 mg BD
Sodium Valproate200 mg BD100 mg1000 mg BDSafety alert *

Beta Blockers

DrugStarting doseIncrementMaximum dose
Propranolol10-20 mg BD10-20 mg120-240 mg/day
Metoprolol25-50 mg/day50mg BD200 mg total daily in BD or TDS regimen
Nadolol40 mg/day40 mg160 mg/day
Timolol10 mg BD10 mg30 mg BD
Atenolol50 mg/day50 mg200 mg/day

CGRP monoclonal antibodies

DrugStarting doseMaximum doseComments
Erenumab70-140 mg monthly Max dose as per licensed indication
Fremanezumab225 mg monthly 675 mg three-monthly Max dose as per licensed indication
Galcanezumab120-240 mg monthly Max dose as per licensed indication

Greater Occipital Nerve Block

DrugStarting doseMaximum doseComments
Greater Occipital Nerve BlockLocal anaesthetic +/- steroids SCNot applicable if using local anaesthetic only4 small RCT – 3 showing reduced headaches frequency over 1-4 weeks
Greater Occipital Nerve Block155 IU195 IUIM every 3 months

Supplements

DrugStarting doseIncrementMaximum dose
Co-enzyme Q10150 mg/day
Magnesium400 mg/day200 mg600 mg/day
Riboflavin400 mg/day

Tricyclic antidepressants

DrugStarting doseIncrementMaximum dose
Amitriptyline10 – 25 mg10 – 25 mg/day150 mg ON

Safety alert *: In girls and women of childbearing potential, valproate should be initiated and supervised by a specialist and only prescribed when other medications have not been tolerated or have found to be ineffective. This is because of 30-40% risk of neurodevelopmental disability in unborn babies exposed to valproate (MHRA April 2017). Valproate should only be prescribed by following the MHRA guidance, including a signed contraceptive plan and signed consent form documenting discussion of the risks (see MHRA website).

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