Migraine

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Management

Table 1: Preventive migraine treatment

Drug class	Drug	Dosage and route	Contraindications	NZ Note
First line medications
Beta blockers	Atenolol	25–100 mg oral twice daily	Asthma, cardiac failure, Raynaud disease, atrioventricular block, depression
	Bisoprolol	5–10 mg oral once daily
	Metoprolol	50–100 mg oral twice daily or 200 mg modified-release oral once daily
	Propranolol	80–160 mg oral once or twice daily in long-acting formulations		Limited range of formulations limits ease of titration. 160mg MR, 10 and 40mg SR.
Angiotensin II-receptor blocker	Candesartan	16–32 mg oral per day	Co-administration of aliskiren
Anticonvulsant	Topiramate	50–100 mg oral daily	Nephrolithiasis, pregnancy, lactation, glaucoma
Second line medications
Tricyclic antidepressant	Amitriptyline	10–100 mg oral at night	Age <6 years, heart failure, co-administration with monoamine oxidase inhibitors and SSRIs, glaucoma
Calcium antagonist	Flunarizine	5–10 mg oral once daily	Parkinsonism, depression	Section 29, not funded
Anticonvulsant	Sodium valproate	600–1,500 mg oral once daily	Liver disease, thrombocytopenia, female and of childbearing potential
Third line medications
Botulinum toxin	OnabotulinumtoxinA	155–195 units to 31–39 sites every 12 weeks	Infection at injection site	Not funded
Calcitonin gene-related peptide monoclonal antibodies	Erenumab	70 or 140 mg subcutaneous once monthly	Hypersensitivity. Not recommended in patients with a history of stroke, subarachnoid haemorrhage, coronary heart disease, inflammatory bowel disease, chronic obstructive pulmonary disease, or impaired wound healing	Not funded
	Fremanezumab	225 mg subcutaneous once monthly or 675 mg subcutaneous once quarterly		Not available
	Galcanezumab	240 mg subcutaneous, then 120 mg subcutaneous once monthly		Not funded
	Eptinezumab	100 or 300 mg intravenous quarterly		Not available

Resources

Migraine diagnosis and management ten steps - Eigenbrodt 2021.pdf - 1.35 MB (f)

Episodic migraine prevention - Silberstein 2012.pdf - 347 KB (f)

Episodic migraine - Loder 2012.pdf - 138 KB (f)

Episodic migraine pediatric - Oskoui 2019.pdf - 327 KB (f)