Beta-blockers : Propranolol LA 60 mg / d increasing as needed up to 160 mg / d . Reactive airway disease ( e . g ., asthma ) and diabetes are usually contraindications . Depression may be worsened by beta-blockers . Nadolol has fewer such CNS side effects ; it is started at 20 mg / d and increased as needed up to 120 mg / d .
Anticonvulsants : Topiramate has been shown to be a very effective migraine prophylactic agent . It is started at 25 mg daily and increased weekly to a goal of 100- 200 mg twice daily . Patients often report cognitive slowing (“ brain fog ”) when they start this medication , but this usually resolves over a few weeks with this plan for a slow increase in the dose . The main side effect at higher doses is a tingling sensation . Rarely , patients can develop kidney issues - metabolic acidosis or kidney stones . If there is a history of stones , regular monitoring of the urine may be necessary .
Sodium valproate 250-500 mg BID is usually well tolerated , but liver function tests and platelets should be monitored . Gabapentin is usually well tolerated . It is started at a low dose of 300 mg a day , with weekly escalating doses to a first target dose of 300 mg three times a day ( 900 mg total ). Then it can be increased gradually to another target dose of 1800 mg total a day ( in 3 divided doses ), or until side effects ( usually sedation ) appear . It has the inconvenience of frequent dosing , but with a low adverse effect profile . Dosing adjustments are necessary for renal insufficiency , and the medication should not be used in children under 12 years old .
All patients are cautioned that migraine symptoms often do not respond quickly to these interventions . Great patience is required of the patient and physician as 6-8 weeks of diet changes or the full dose of any new medication may be needed before benefits are seen .
Anxiety , depression , and even panic attacks are frequent accompanying diagnoses in these patients . These diagnoses should be recognized and discussed . The choice of a prophylactic medication may also be influenced by these other conditions .
One of the best resources for migraine therapeutics currently available is Lawrence Robbins ’ Management of Headache and Headache Medications . It very