This protocol addresses the clinical situation in which a patient with migraine with aura experiences three or more attacks per month — with significant impact on quality of life, severe symptoms, or persistent aura — and first-line preventive monotherapy has not achieved an adequate response.
Frequent migraine attacks (three or more per month) with negative impact on quality of life, severe symptoms, or persistent aura. In this setting, active migraine prevention is indicated alongside non-pharmacological approaches.
First-line preventive monotherapy, titrated slowly to the highest tolerated dose, did not achieve the required response: a reduction in migraine attack frequency of 50% or more, assessed at two months after reaching the final dose.
In frequent migraine attacks or migraine patients with severe symptoms or persistent aura, migraine prevention should be offered in addition to prevention by education and behavioural therapy.
Three or more migraine attacks per month with negative impact on quality of life;
If no improvement in migraine frequency is achieved within two months after the targeted or tolerated final dose, a switch should be made to a different substance.
If there is no or only inadequate response to a monotherapy, combination therapy may be considered.
In smaller studies, combinations of beta blockers, or flunarizine with topiramate, as well as valproate and beta blockers were effective.
Migraine prevention is considered effective when it achieves a reduction of the migraine attack frequency of 50% or more.
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