Migraine prophylaxis

Antidepressants are used in neuropathic pain and migraine prophylaxis. Tricyclics require monitoring of plasma drug concentrations to achieve optimal effect... 

The P-blockers propranolol and timolol are FDA-approved for migraine prophylaxis, but other drugs in the class are also as effective.46 Cautious dosage titration is advised for those patients who do not have other indications for P-blocker use. Rizatriptan interacts with propranolol and thus dosages must be titrated downward, or another triptan chosen for abortive therapy.36 Comorbid reactive airway disease is a relative contraindication to P-blocker prophylaxis, and patients with cardiac conduction disturbances should be closely monitored. Calcium channel antagonists are often used when patients cannot tolerate P-blockers. They are purported to beneficially... 

Their beneficial effects in migraine prophylaxis are independent of antidepressant activity and may be related to downregulation of central 5HT2 and adrenergic receptors. 

TCAs are usually well tolerated at the lower doses used for migraine prophylaxis, but anticholinergic effects may limit use, especially in elderly patients or those with benign prostatic hyperplasia or glaucoma. Evening doses are preferred because of sedation. 

Selective serotonin reuptake inhibitors are considered to be less effective than TCAs for migraine prophylaxis and should not be considered first- or second-line therapy. However, they may be beneficial when depression is a significant contributor to headache. Preliminary data suggest a possible benefit with venlafaxine. 

Topiramate is recently approved by the FDA for migraine prophylaxis. Dose is initiated at 25 mg/day and increased slowly to minimize side effects, which may include paresthesias, fatigue, anorexia, diarrhea, weight loss, difficulty with memory, and nausea. Kidney stones, acute myopia, acute angle-closure glaucoma, and oligohidrosis have been infrequently reported. 

In addition to the agents on the following pages, propanolol and timolol are indicated for migraine prophylaxis. 

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