migraine prophylaxis

[tinykitty]

I was wondering if you neuro gurus had any preferences for migraine prophylaxis. It seems that most of the med classes have pretty significant side effects (e.g., TCAs=sedation, weight gain, constipation; B-blockers=fatigue, exercise intolerance; calcium channel blockers=constipation; depakote=sedation, weight gain). How about ACE inhibitors or ARBs? I was just reading a couple of studies that shows that these might be effective, but the studies are from a few years ago. Why aren't these classes used more often for migraine PPX? Thanks much for any advice/expertise.

---

Members don't see this ad.

 

[gallant2m]

if u've tried most of those, take Topamax or trileptal, as ive had success with some of those AEDs.

 

[neurologist]

I was wondering if you neuro gurus had any preferences for migraine prophylaxis. It seems that most of the med classes have pretty significant side effects (e.g., TCAs=sedation, weight gain, constipation; B-blockers=fatigue, exercise intolerance; calcium channel blockers=constipation; depakote=sedation, weight gain). How about ACE inhibitors or ARBs? I was just reading a couple of studies that shows that these might be effective, but the studies are from a few years ago. Why aren't these classes used more often for migraine PPX? Thanks much for any advice/expertise.

UNIVERSAL TRUTH #1: There is no "sure thing" in headache prophylaxis. When it comes to pain management, I am a firm believer in the "50/50 rule" (e.g., on any given medication, 50% of patients will have 50% improvement; the other 50% get no benefit).

UNIVERSAL TRUTH #2: ALL medications have potential side effects. You may have to choose between mild to moderate side effects and maybe a few more or less headaches.

ARBs and ACEs may have some value in some patients, just like every other med. They aren't used much because the research is relatively new and because the drug companies haven't been pushing them for the migraine indication yet. The other poster who mentioned Topamax and Trileptal is correct in that those meds are being used more and more (especially Topamax). However, they are not without side effects either: topamax can cause paresthesias, cognitive slowing and forgetfulness, extreme weight loss, and kidney stones, among other things. Trileptal is well known for its hyponatremic effect.

Since honesty is the best policy, I tell all my patients right off the bat that:
1) migraine prophylaxis is basically just lots of trial and error until we find the medication that gives maximal relief with minimal side effects, and what that medication turns out to be will vary from person to person.
2) they need to have realistic expectations: they will always have some migraines because NO treatment is 100% effective

 

[gallant2m]

however, you think by telling them topamax causes weight loss, thats going to DETER them from using it, or now have people standing in lines for the stuff.

 

[plouffes]

however, you think by telling them topamax causes weight loss, thats going to DETER them from using it, or now have people standing in lines for the stuff.

I take Topamax 100mg BID for migraine ppx and have been for about 2 years now. Although I still get migraines they are not nearly as severe or as frequent. I, however, still get them about twice/week. In the past, I have tried pamelor (TCA), lamictal (AED), and keppra (AED). Topamax has been the most effective. In the beginning I lost some weight (approx. 10 lbs. - I was only about 120 lbs. to begin with..) mostly because it significantly decreased my appetite and changed the taste of carbonated beverages. The first few months the side effects were almost unbearable (fatigue, parathesia, 'mixing up' my words, forgetfulness) but I am glad I stuck with it. Now, I just experience some occassional parathesias of my face, hands, and feet (mostly if I do not eat or do not drink enough water), some hair loss (but not severe), and I think I am a little more fatigued than most.

 

[mlw03]

i'm just an MS3, but have just been doing a neuro rotation. The attending I was with is a big fan of pregabalin (Lyrica) for lots of stuff, including migraine prevention and neuropathic pain. I don't know if there's a ton of evidence supporting this, but he claims that it helps some of his patients that weren't getting good prophylaxis any other way.

Another treatment I've seen is Botox into the frontalis and temporalis muscles. I know the evidence is that it doesn't work, but I've personally talked to patients who've said their frequency of migraine dropped significantly after beginning q 3 month Botox injections.