In this post, I am going to discuss the ins and outs of prescribing a daily medication for migraine prophylaxis. In the last post, I identified one migraine/week as a benchmark for considering a daily preventive medication. Here’s the run down on the basic daily meds that primary care providers could start for their patients with frequent migraine.
There are several groups on medications commonly used to prevent migraine. They are antihistamines (cyproheptadine), tricyclic antidepressants (amitriptyline, nortriptyline), anticonvulsants (topiramate, zonisamide, gabapentin), beta blockers (propranolol) or calcium channel blockers (verapamil). Your choice is based on age, other comorbidities, side effects you want to avoid (or can help with other issues). As with all things headache, you start with low dosing and increase as needed (low and slow). For most of these medications, significant side effects include mental clouding, sedation, and at times, mood alteration (irritability).
Cyproheptadine (Periactin) is an antihistamine with anti-serotonergic and calcium channel blocker properties. It is most effective as a migraine preventive before puberty. Expected side effects include sedation and weight gain/increased appetite, and is generally taken at bedtime. For kids who have trouble with sleep, the sleepiness can help establish a better sleep pattern. If dietary intake is an issue, this can help. As is often the case with antihistamines, there can sometimes be some irritability or mood issues. I always mention this, and if a child has had a paradoxical reaction to Benadryl, I don’t use it. Starting dose is 2-4mg QHS, and it does come as a liquid, which does not taste too bad.
Tricyclic antidepressants: the most common TCAs for pediatric headache prevention are amitriptyline and nortriptyline. Amitriptyline is more effective but has more side effects than nortriptyline. The typical side effects are sedation and mental clouding. Since nortriptyline does come as a (bad tasting) liquid, it is used more often in the youngest kids. The usual starting dose for amitriptyline is 10mg QHS, with slow titration as needed. You should get an EKG to make sure there are no heart rhythm abnormalities first. Again sleepiness from the medication can help with troubled sleeper. The main things to monitor are daytime sleepiness and mental clouding. It’s a fine dance to achieve medication effectiveness with minimal side effects.
Antiepileptic drugs, most commonly topiramate and gabapentin are also among the first line of migraine preventive medications. From our knowledge of migraine pathophysiology, it seems that these medications can alter the migrating wave of regional cortical excitation followed by a prolonged period of neuronal depression that happens during a migraine attack. These medications do vary with their side effects, though both cause mental clouding.
Topiramate is one of our starter preventive medications, can cause paresthesias and significant appetite suppression, and generally not sedating. Dosing can be daily or BID, lowest dose is the 15mg sprinkle cap, no liquid form is available. If topiramate seems somewhat effective but there are too many side effects to continue, you could try zonisamide, next generation of topiramate, less effective but less side effects.
Gabapentin does cause sedation, may lead to weight gain as well. Dosing is at bedtime to start, though depending on toleration, it can be given up to TID. At most I will use BID dosing (bigger dose at bedtime), as that midday dose is often missed. It comes in capsule form, smallest dosing is 100mg, though it does come as a liquid, helpful for younger children. I might choose gabapentin if there is an element of occipital neuralgia or neck pain.
Antihypertensive drugs: These medications dilate the cerebral blood vessels and interacts with serotonergic systems involved in migraine pathogenesis. They can be effective in migraine prevention, but it is also unclear how exactly these mechanisms work.
Propranolol (beta blocker, Inderal) is one of the most common medications used for migraine prevention. It is contraindicated for kids with asthma or RAD, and might not be a good choice for athletes as it blocks the effect of adrenaline, reduce blood pressure and slows the heart beat. Verapamil (calcium channel blocker), is helpful for those patients with significant dizziness or vertigo. It should be avoided for any patients with significant cardiac abnormalities. Dosing for both medications is generally BID, though after therapeutic dose has been established, they can be transitioned to an extended release product. I advise being vigilant with hydration and having electrolyte-rich drinks and salty snacks available due to the likelihood of lightheadedness. Neither of these medications cause mental clouding.
A few tips:
- A word on mental clouding- kids have no idea what you are talking about when you say mental clouding. I describe it as ‘feeling dumb or not being able to think straight’ and they understand that. Since learning is their job, it’s an important consideration; unfortunately, nearly all of our preventive medications have this as a side effect.
- A specific consideration for TCAs: amitriptyline can be lethal taken in large doses. If there are any mental health concerns, the parents need to know this and take appropriate safety steps. For my teens going off to college, if I have not told them this before, I make sure they know about the lethality of amitriptyline and advise keeping it locked up, under wraps, out of the hands of a depressed schoolmate. It’s scary but they need to know.
- It usually takes weeks to 1 month to notice any positive effects from these medications on migraine frequency and severity. Families need to have patience, as the higher the dosing, the more likely the side effects.
- A common situation: your patient thinks the medication is not helping them. The teen may just stop the medication or forgets to take it for a few days. Sometimes these episodes show the patient that medications are actually helpful (or not). Can be a useful experience.
- One helpful tip for the reluctant patient is to stress that taking a daily medication is not forever. Setting a time line (4-6 months), or deciding to wean off at the end of the school year, can help with the buy-in.
So those are the basic medications used for migraine (and other headache) prevention. Starting a daily medication is always a group decision between the provider, family and patient, and no matter how strongly you and/or the parents feel about medications, your patient may not want to do this. I feel strongly that without full buy-in from the patient for taking a daily medication, there is no point to doing it. Without the patient’s agreement and cooperation, this is a set up for daily family arguments, inconsistency and noncompliance.
Plus, I think in the world of headache and migraine, kids/teens deserve to have a say in their treatment. It is always worth a conversation with your patient about why they do not want to take a daily medication. Questions can be answered, reassurance given, and the importance of daily compliance stressed. If in the end they are not willing to commit, then that’s it. No matter what the parent wants, a daily medication demands daily compliance. Many of our older kids and teens are able to take agency for their own health, and in doing so, they can partner with you in improving their health.