Prevention of Migraine

Abstract

Patients with frequent or severe migraine headaches and those who cannot take vasoconstrictors or are refractory to acute treatment should receive preventive treatment. 1,2 Menstrual migraine attacks may sometimes be prevented by a brief course of an NSAID or triptan, particularly frovatriptan or naratriptan, taken for several days before and after the onset of menstruation. 3,4 Preventive therapy is generally not recommended during pregnancy. Beta BlockersBeta blockers are commonly used for prevention of migraine. Propranolol (Inderal LA, and others) and timolol are the only beta blockers approved by the FDA for this indication, but metoprolol (Lopressor, and others), nadolol (Corgard, and generics), and atenolol (Tenormin, and generics) are also effective in preventing migraine. 2 All beta blockers can cause fatigue, exercise intolerance, and orthostatic hypotension, and should not be used in patients with decompensated heart failure. All are relatively contraindicated in patients with asthma. Patients with migraine often have comorbid depression, which may be aggravated by beta blockers. PregnancyIntrauterine growth retardation, small placentas, and congenital abnormalities have been reported with use of propranolol during pregnancy. Atenolol has been associated with the birth of small for gestational age infants and, at high doses, with embryofetal resorptions in animals. Antiepileptic DrugsValproate (Depakote, and others) and topiramate (Topamax, and generics) are similarly effective in decreasing migraine frequency and are FDA-approved for migraine prevention. About 50% of patients achieve a Ն50% reduction in headache frequency with these drugs. 5 In randomized, double-blind trials, topiramate was at least as effective as propranolol for migraine prevention. 6,7 Topiramate has reduced the number of migraine headache days per month and improved associated symptoms in patients with chronic migraine (Ն15 headache days/month for Ն3 months) and medication overuse headache. 8,9 In a trial in pediatric patients, however, topiramate was no better than placebo in preventing migraine. 10 Adverse EffectsAdverse effects of valproate include nausea, fatigue, tremor, weight gain, and hair loss. Acute hepatic failure, pancreatitis, and hyperammonemia (in patients with urea cycle disorders) occur rarely. Other adverse effects include polycystic ovary syndrome, hyperinsulinemia, lipid abnormalities, hirsutism, and menstrual disturbances. Topiramate commonly causes paresthesias; fatigue, language and cognitive impairment, taste perversion, weight loss, and nephrolithiasis can also occur. Topiramate can rarely cause secondary narrow-angle glaucoma, oligohydrosis, and symptomatic metabolic acidosis. PregnancyUse of topiramate or valproate during pregnancy has been associated with congenital malformations 11,12 ; neither drug should be used for migraine prevention in pregnant women.