Sandra Mazurkiewicz, Kamila Magdalena Czora-Poczwardowska, Konrad Sarnowski, Wiktoria Biela, Szymon Cysak, Weronika Jarczak, Kinga Andrzejczak, Julia Gronowska, Michał Szulc, Przemysław Mikołajczak, Radosław Kujawski
Pharmacotherapy for migraine prophylaxis – a narrative review
2026-04-17
Background. Migraine is a common neurological disorder that remains a therapeutic challenge. Despite many available pharmacological options, effective prophylaxis is difficult to achieve for a significant proportion of patients.
Objective. To present the main classes of drugs used in migraine prevention with particular emphasis on their efficacy, tolerability, and limitations related to side effects and availability.
Materials and methods. This narrative review encompassed publications published by early 2025 and identified through PubMed, Cochrane Library, and Google Scholar. The analysis included systematic reviews, meta-analyses, and clinical studies evaluating the efficacy and safety of drugs used for migraine prophylaxis, including beta‑blockers, antiepileptic drugs, antidepressants, and therapies targeting the calcitonin gene-related peptide (CGRP) pathway.
Results. Among the most recommended drugs for migraine prophylaxis, the strongest evidence of efficacy supports beta-blockers (propranolol, metoprolol), certain antiepileptic drugs (topiramate, valproate), and tricyclic antidepressants such as amitriptyline. Although these agents are considered first-line treatments, their use is often limited by adverse effects - such as drowsiness, cognitive impairment, or weight gain - which frequently lead to treatment discontinuation. Increasing attention is being directed toward newer medications targeting the CGRP pathway. Both monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) and oral CGRP receptor antagonists - so-called gepants (rimegepant, atogepant) demonstrate high efficacy and excellent tolerability. Studies have shown that in some patients, these therapies significantly reduce the number of migraine days, often more effectively than traditional treatments, with fewer adverse effects. However, their widespread use remains limited by high costs and low availability.
Conclusions. Classical agents such as propranolol and topiramate remain among the most commonly chosen first-line options for migraine prevention owing to their extensive clinical experience, low cost, and wide availability. However, the latest guidelines (AHS 2024) together with recent high-quality meta-analyses (e.g., Lampl et al. 2023) demonstrate that gepants and CGRP-targeted monoclonal antibodies provide the most favourable combination of efficacy and tolerability. They should therefore be regarded as an equivalent first-line option, without the prerequisite of failure of conventional therapies.. The choice of therapy should be individualized based on efficacy, safety, and access.
Keywords: migraine, prophylaxis, pharmacotherapy, CGRP, beta‑blockers.
© Farm Pol, 2025, 81(9): 551–562