Migraine prophylaxis: Prescription treatment options

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.

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.

Valproate

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

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

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.

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.

Tricyclic antidepressants

• Amitriptyline
• Nortriptyline

Serotonin noradrenaline reuptake inhibitors (SNRIs)

• Duloxetine
• Venlafaxine

Selective serotonin reuptake inhibitors (SSRIs)

• Citalopram
• Escitalopram
• Paroxetine
• Fluoxetine
• Sertraline

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.

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.

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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