There are many options when it comes to deciding on the right prophylactic medicine for your headache patient: anti-epileptic (anticonvulsant) drugs, antidepressants, beta-blockers, and calcium channel blockers.
Using anti-epileptics (anticonvulsants) for headache prophylaxis
Anti-epileptics are some of the most effective drugs for migraine prophylaxis. Anti-epileptics are also often used in post-traumatic headaches and the trigeminal cephalalgias.
Typically you would administer valproate at a dose rate between 500 and 1500 mg per day. It is important to note, that valproate can cause neural tube defects and has been associated with polycystic ovarian syndrome, so its use in women of child-bearing age is limited. Also, it has been noted that hepatotoxicity can occur.
Topiramate can be helpful in patients with cluster headaches. Topiramate is frequently associated with paresthesia and may cause memory issues and weight loss. Rarely, it can cause acute narrow angle glaucoma and nephrolithiasis.
Gabapentin may be effective in tension-type headaches. However, if there are mixed migraine features, gabapentin can be ineffective. In these cases, neurologists often substitute divalproex and topiramate as preventative agents.
Using antidepressants for headache prophylaxis
Tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and serotonin noradrenaline reuptake inhibitors (SNRIs) have all been found to be effective in tension-type headache as well as migraine.
Serotonin noradrenaline reuptake inhibitors (SNRIs)
Selective serotonin reuptake inhibitors (SSRIs)
Similar to when you are treating a patient with depression, several weeks may be needed to assess the efficacy of the treatment, and the dosage may need adjustment.
Using beta-blockers for headache prophylaxis
Beta-blockers (such as propranolol, timolol, nadolol, atenolol, and metoprolol) are often used as a first line treatment when there is comorbid hypertension or anxiety.
Treatment may take a few weeks to show an effect and the dosage may need adjustments.
If a beta-blocker is indicated, it is usually prescribed at the following typical dose:
- Propranolol, 120–240 mg daily
- Nadolol, 80–240 mg daily
- Metoprolol, 200 mg daily
- Atenolol, 100 mg daily
Side effects include exercise intolerance, bradycardia, and erectile dysfunction.
Using calcium channel blockers for headache prophylaxis
Calcium channel blockers (such as verapamil and flunarizine) are also effective prophylactic agents for patients suffering from migraines (however, flunarizine is not available in the US).
It should be noted, however, that these drugs generally require higher doses and can have side effects including cardiac arrythmias, such as atrioventricular block and bradycardia.
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