Comparative Effectiveness of Migraine Preventive Medications: The APT Comparison Study

Eligibility Criteria

• * Adults, 18-70 years of age at the time of enrollment
• * Migraine with aura, migraine without aura, and/or chronic migraine; according to ICHD-3 diagnostic criteria. (Those with daily or continuous headaches are not excluded.)
• * Migraine onset prior to 50 years of age
• * Migraine present for at least 12 months at the time of enrollment
• * At least four "moderate to severe headache days" per month (by patient self-report and then confirmed during four-week pre-randomization headache diary phase) A "moderate to severe headache day" is defined as a day during which there is a headache of moderate to severe intensity that lasts for at least four hours, or a day on which a migraine-specific acute medication is taken to treat headache.
• * If already taking a migraine preventive treatment, willing to continue with that treatment without dose change during the first 16 weeks of the study, including the 4-week run-in phase and 12-week randomized phase.
• * Not pregnant or breastfeeding
• * Women of childbearing potential must agree to use effective methods of contraception to reduce the risk of pregnancy.
• * Willingness and ability to provide informed consent.
• * Willingness and ability to complete all research visits.
• * Contraindications to taking atogepant, propranolol, or topiramate.
• * Currently taking atogepant, propranolol, or topiramate\*
• * Previously took atogepant, propranolol, or topiramate\*
• * Unwillingness to take atogepant, topiramate, or propranolol.
• * Current use of a CGRP-targeting preventive medication or beta-blocker
• * Migraine with brainstem aura
• * Hemiplegic migraine
• * Retinal migraine
• * Migraine aura without headache (exclusively)
• * Pure menstrual migraine
• * Trigeminal autonomic cephalalgias
• * Facial neuralgias
• * Secondary headache disorders (medication overuse headache is not an exclusion)
• * Migraine preventive treatment has been started or dose has been changed within 12 weeks prior to potential enrollment.
• * Used opioids or butalbital on five or more days per month on average for at least 3 months prior to enrollment.
• * Current or past epilepsy
• * Severe hepatic impairment
• * Moderate or more severe renal impairment \* Occasional as needed use of propranolol, currently or in the past, is not an exclusion, such as taking as needed propranolol for treatment of anxiety.