Migraine - Prophylactic treatment

10 important questions on Migraine - Prophylactic treatment

What patients should migraine prophylaxis be considered for?

>/= 4 migraines per month [2 days/week OR 3/mo], have migraines that decrease quality of life, if need other treatment

How is a migraine prophylactic drug chosen?

Based off medication side effect profile.
Trial of min of 8 weeks, then switch if no response. Continue x6-12 mo if partial response.

Antihypertensives for migraine prophylaxis

Beta blockers - best evidence with propranolol, timolol, metoprolol.
alt: lisinopril, candesartan
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Migraine prophylaxis + interested in weight loss

Topiramate (causes weight loss)

Contraception for simple migraine (no aura)

Extended cycle or continuous PO or vaginal ring

Contraception for migraine + aura

Progestin only pill

Beta blocker warnings and side effects

Caution in bronchospastic diseases (asthma, COPD) [esp. With non selectives (propranolol, timolol)].
Bradycardia, hypotension, impotence, CNS effects (fatigue, dizzy, depression - more with propranolol, the most lipophilic), cold extremities (exacerbate Raynauds)

Divalproex and valproic acid BBW and warnings/side effects

Fetal harm, hepatic failure, pancreatitis
Weight gain>loss, thrombocytopenia, alopecia, increased ammonia

Topiramate warnings and side effects

Fetal harm, metabolic acidosis, nephrolithiasis, oligohidrosis, visual field defects, increased ammonia, secondary angle-closure glaucoma
Weight loss, somnolence, cognitive impairment, reduced efficacy of PO contraceptives

If only 2 CGRPs are PO, what form are the remaining CGRPs?

Injectable monoclonal antibodies

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