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Medications for preventive treatment of migraine in adults: Comorbid factors for drug selection

Medications for preventive treatment of migraine in adults: Comorbid factors for drug selection
Drug class (and examples) Factors favoring use Factors favoring avoidance
Beta blockers
  • Atenolol
  • Metoprolol
  • Nadolol
  • Propranolol
  • Hypertension*
  • Cardiovascular disease (eg, HFrEF, MI within previous 3 years, atrial fibrillation, angina pectoris)
  • Bronchospastic disease
  • Age >60 years
  • Depression
  • Fatigue
  • Sexual dysfunction
  • Tobacco use (diminished efficacy of propranolol)
Antidepressants
  • Amitriptyline
  • Venlafaxine
  • Depression
  • Anxiety disorders
  • Insomnia
  • Neuropathic pain
Amitriptyline
  • Suicidality (TCAs dangerous in overdose)
  • Cardiac conduction disorders
  • Anticholinergic effects (dry mouth, constipation, urinary retention, etc)
  • Seizure disorder
  • Glaucoma

Venlafaxine

  • Hypertension
  • Seizure disorder
  • Glaucoma
Antiseizure medications
  • Topiramate
  • Valproate
  • Seizure disorder
  • Mood disorder (valproate)
  • Obesity (topiramate)
Topiramate
  • Weight loss
  • Cognitive impairment
  • Depression/mood problems
  • Pregnancy (teratogen)
  • Kidney stones

Valproate

  • Weight gain
  • Diabetes/metabolic syndrome
  • Menstrual irregularities
  • Pregnancy (teratogen)
  • Hair loss
CGRP antibodies/antagonists
  • Erenumab
  • Galcanezumab
  • Fremanezumab
  • Eptinezumab
  • Rimegepant
  • Atogepant
  • Infrequent dosing options available (some agents may be administered monthly or quarterly)
  • Active or high risk cardiovascular or cerebrovascular disease
  • Pregnancy (limited safety information)
  • Hypertension
  • High cost
Several medications are available for preventive treatment of migraine. The selection of specific agent is individualized by factoring comorbid conditions, medication adverse effects, patient preferences, and cost. Refer to UpToDate for additional details.

CRGP: calcitonin gene-related peptide; HFrEF: heart failure with reduced ejection fraction; MI: myocardial infarction; TCAs: tricyclic antidepressants.

* Although beta blockers may provide modest benefit for lowering of blood pressure, they are not used for first-line treatment of primary hypertension absent a compelling indication. Refer to UpToDate review of drug therapy choice in primary hypertension.
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