Migraine Preventative Choices NHS Grampian Style

I’ve recently re-read an old Patient Information Leaflet produced by the UK Grampian regional health authority which listed its first choice as being Blood Pressure Medications, ie Beta blockers (Propranolol, Atenolol, Metoprolol), ARB class (Candesartan) and ACE Inhibitors (Lisinopril) and its second as antidepressants either the tricyclics (Amitriptyline, Noritriptyline, Dosulepin) or the SNRI Venlafaxine. Then the Anti-epileptic medications (their words not mine) Topiramate, Sodium Valproate and Gabapentin and the Antihistamine medication - Pizotifen. (First choice for children).

I was interested to read it stated 80% people found with slow titration that they could tolerate Topiramate. That it stated many people needed 100mg Amitriptyline for control and up to 150mg was possible. That they attributed the low uptake of Pizotifen to the high doses needed (up to 4.5mg) and the fact that the text seemed to infer a dose of 240mg of Propranolol would need to be maintained, which is way over the National recommendation of 160mg. Written for patients on their own Scottish clinics on recommendation of their own experts just goes to show how opinions vary. It’s obviously what works for them.

I was contemplating putting a link on here but when my broadband failed me and I was forced to re-find the original I hit upon what must be a more recent update which contains even more useful bits of information so decided to link that instead. It mentions Topiramate can take between 3-4 months to work! It lists Candesartan, Effexor, Gabapentin and Sodium Valproate as ‘treatment should only be instigated on the recommendation of a migraine specialist’ which certainly surprised me. Why such restrictions one wonders. It refers to the ‘special UK status’ of Flunarizine which can only be prescribed by a migraine specialist and issued from a hospital pharmacy. It also states the Flunarizine is not widely available throughout the UK. Includes references to the special status of fertile females, pregnancy and preventatives together with a section on the ‘highly specialised restricted use’ of Botox. Altogether a worthwhile read. Might be a useful article to put in front of an obliging UK doctor who was willing to help but not quite sure? Helen



That’s very useful. Thanks.

I wish I’d been in that 80% that could tolerate topiramate. Even in tiny doses that stuff acted like a serious toxin in my system. My friends thought I was dying. So did I.


Some days I wish I was in the 80%? that was prepared to try taking them. Never was keen. Then I read the doctor on here from Singapore I think she was who got MAV and nearly died at the prospect of having to take them. Helen

The pamphlet does say discontinue as soon as possible. I took Trokendi XR (topiramate) for 29 days in February 2018. At this point, it’s obvious the nerve damage to my hand is permanent. MAV’s kicking my ass. That’s ok. At least it’s not a neurotoxin that is proven to lead to reduced IQ, nerve damage and dementia. I’ll take my chances.

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Especially helpful when you are shopping with your doc to pick your next poison :stuck_out_tongue:


Thanks Helen. This is very informative

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Doesn’t seem long ago 37.5mg was being considered for MAV, now in this article it states:

Adult dose: 75-150mg daily. Venlafaxine 75-150mg per day has a SIGN grade B recommendation as an effective alternative to tricyclic antidepressants for the prophylaxis of migraine

As treatment with drugs seems the main way forwards for most it’s reassuring to see treatment seems to be evolving in line.