Recommended doses for migraine preventive treatment
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
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
Comments
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
IM every 3 months
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 *: 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)
