This protocol addresses patients with migraine without aura experiencing three or more attacks per month — or attacks regularly lasting beyond 72 hours — with significant impact on quality of life, in whom an initial high-evidence preventive agent did not achieve adequate control.
Three or more migraine attacks per month with negative impact on quality of life, or migraine attacks which regularly last longer than 72 hours — and first-line preventive treatment has not achieved the target response.
The preceding line used drug prophylaxis with a high-evidence preventive agent — propranolol, metoprolol, bisoprolol, flunarizine, topiramate, valproic acid, or amitriptyline — titrated slowly to the highest tolerated dose.
Escalation to this protocol is appropriate when that course did not achieve a 50% or greater reduction in migraine attack frequency, evaluated two months after reaching the highest tolerated dose.
When first-line monotherapy proves inadequate, this protocol defines a structured approach — either switching to an alternative preventive agent or moving to a combination strategy. Specific substance selection and the decision criteria guiding each option are detailed in the full regimen.
DOI: 10.1177/2514183X1882337