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Migraine preventives : doses, side effects and contra-indications

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Migraine

<span style="font-weight: 400;">A migraine is a powerful headache that often happens with nausea, vomiting, and sensitivity to light. Migraines can last from 4 hours to 3 days, and sometimes longer.Most people start having migraine headaches between ages 10 and 40. But many women find that their migraines improve or disappear after age 50.</span><i><span style="font-weight: 400;">Référence : webmd.com, </span></i><i><span style="font-weight: 400;">https://www.webmd.com/migraines-headaches/migraines-headaches-migraines#1</span></i><i><span style="font-weight: 400;">  consulted on july 4</span></i><i><span style="font-weight: 400;">th</span></i><i><span style="font-weight: 400;">,2019.</span></i>
" >Migraine [1] Canada is a patient association, not a treating health care provider. MC cannot provide medical advice. Nevertheless, basics on medications are public knowledge and many people ask about this type of medical information. This table is given as general reference. Any decision to take a medication should be discussed with a health care provider. 

Table : Migraine Preventives 


Usual doseMain side effects [2]Choose for patients withAvoid in patients with
Frequently used (brand name)
Amitriptyline [3]
Elavil

Nortriptyline
Aventyl
10 to 50 mg at bedtimeWeight gain
Drowsiness
Confusion
Urinary retention
Constipation
Dry mouth, eyes
Orthostatic hypotension
Insomnia
<span style="font-weight: 400;">Medical providers have known for over a century that there is an association between poor sleep and the frequency and intensity of migraine and other pain syndromes. Insomnia, also referred to as psychophysiologic insomnia by many, is one type of poor sleep. Other common types of sleep difficulties include sleep apnea, frequent snoring, and excessive daytime sleepiness.</span><span style="font-weight: 400;">Insomnia, of one or both types, is a common finding amongst individuals with chronic migraine. In many cases, insomnia may stem from other medical problems which cause chronic pain (making it difficult to sleep comfortably) or which disrupts normal sleeping patterns.</span><i><span style="font-weight: 400;">Reference : by Rashmi Halker, MD; Bert Vargas, MD; and David Dodick, MD,</span></i><i><span style="font-weight: 400;">https://americanmigrainefoundation.org/resource-library/sleep-insomnia-migraine/</span></i><i><span style="font-weight: 400;"> ,july 4</span></i><i><span style="font-weight: 400;">th</span></i><i><span style="font-weight: 400;">,2019</span></i><i><span style="font-weight: 400;"> </span></i>
" >Insomnia
[4]
Other pain
Tension type headache* no effect on depression at lower doses
Overweight
Glaucoma
Prostate disease
Heart block
Bipolar disorder
Elderly
Propranolol
Inderal

Nadolol
Corgard
80 to 160 mg qd (slow release or BID)Fatigue
Reduced exercise tolerance
Weight gain
Orthostatic hypotension
Sexual dysfunction
Nightmares
Hypertension
Anxiety
Essential tremor
Raynaud
Asthma
Heart block
Hypotension
bradycardia
Candesartan
Atacand
8 to 16 mg qdHypotension
Dizziness
<span style="font-weight: 400;">Dizziness is a term used to describe a range of sensations, such as feeling faint, woozy, weak or unsteady. Dizziness that creates the false sense that you or your surroundings are spinning or moving is called vertigo.</span><i><span style="font-weight: 400;">Reference : By Mayo Clinic Staff,</span></i> <i><span style="font-weight: 400;">https://www.mayoclinic.org/diseases-conditions/dizziness/symptoms-causes/syc-20371787</span></i><i><span style="font-weight: 400;"> , </span></i><span style="font-weight: 400;">july 1</span><span style="font-weight: 400;">st</span><span style="font-weight: 400;">,2019</span>
" >Dizziness
[5]
HypertensionHypotension
Topiramate
<span style="font-weight: 400;">Topiramate (Topamax) is an antiepileptic drug recently approved by the U.S. Food and Drug Administration (FDA) for prevention of migraine headache in adults. Its exact mechanism of action is uncertain, but it is known to affect neuronal hyperexcitability,1 which is one probable factor in the development of migraine.</span><span style="font-weight: 400;"> </span><i><span style="font-weight: 400;">Reference:  by JANE HUNTINGTON, M.D., and CARRIE L. YUAN, PHARM. D., </span></i><i><span style="font-weight: 400;">https://www.aafp.org/afp/2005/1015/p1563.html</span></i><i><span style="font-weight: 400;"> ,consulted on july 08</span></i><i><span style="font-weight: 400;">th</span></i><i><span style="font-weight: 400;">,2019</span></i>
" >Topiramate
[6]
Topamax
50 to 200 mgCognitive difficulties
Paresthesias
Weight loss
Kidney stones
Anxiety, mania
Visual disturbances
Glaucoma (rare)
Obesity
Epilepsy
Essential tremor
Chronic migraine [7]
Kidney stones
Glaucoma
Use with caution in depression/anxiety
Onabotulinum Toxin Type A
Botox
155 to 195 units SC or IMLocal pain after injections
Cosmetic asymmetry in the face (dropped brow etc)
Neck weakness (rare)
Chronic Migraine
<span style="font-weight: 400;">A migraine is a powerful headache that often happens with nausea, vomiting, and sensitivity to light. Migraines can last from 4 hours to 3 days, and sometimes longer.Most people start having migraine headaches between ages 10 and 40. But many women find that their migraines improve or disappear after age 50.</span><i><span style="font-weight: 400;">Référence : webmd.com, </span></i><i><span style="font-weight: 400;">https://www.webmd.com/migraines-headaches/migraines-headaches-migraines#1</span></i><i><span style="font-weight: 400;">  consulted on july 4</span></i><i><span style="font-weight: 400;">th</span></i><i><span style="font-weight: 400;">,2019.</span></i>
" >migraine
[1] only
Neuromuscular disease
Coagulation disorders are not a strict contra-indication.
CGRP monoclonal antibodies (MABs)
Erenumab
(Aimovig)
70 mg or 140 mg q 28 daysConstipation
Skin reaction at the injection site
Pain in muscles and joints
Allergy /hypersensitivity reaction
** Other reactions not seen in studies but reported in practice: weight gain, hair loss, nightmares, anxiety, increase of the headache
Frequent episodic (8-14 days/month) or chronic (15+ days per month) migraine who have failed previous preventive treatments (will not be covered as first line treatment)
Women who want to get pregnant
People with allergy to a CGRP antibody
At risk for constipation (plan for management) Uncontrolled vascular disease
Galcanezumab
(Emgality)
Load 240 mg120 mg q 28 daysConstipation
Skin reaction at the injection site
Pain in muscles and joints
Allergy /hypersensitivity reaction
** Other reactions not seen in studies but reported in practice: weight gain, hair loss, nightmares, anxiety, increase of the headache
Frequent episodic (8-14 days/month) or chronic (15+ days per month) migraine who have failed previous preventive treatments (will not be covered as first line treatment)
Women who want to get pregnant
People with allergy to a CGRP antibody
At risk for constipation (plan for management) Uncontrolled vascular disease
Fremanezumab
(Ajovy)
225 mg q 28 days or 675 mg q 3 monthsConstipation
Skin reaction at the injection site
Pain in muscles and joints
Allergy /hypersensitivity reaction
** Other reactions not seen in studies but reported in practice: weight gain, hair loss, nightmares, anxiety, increase of the headache
Frequent episodic (8-14 days/month) or chronic (15+ days per month) migraine who have failed previous preventive treatments (will not be covered as first line treatment)
Women who want to get pregnant
People with allergy to a CGRP antibody
At risk for constipation (plan for management) Uncontrolled vascular disease
Natural products and supplements
Magnesium
<span style="font-weight: 400;">Magnesium is a natural mineral that helps keep blood pressure stable, promotes heart health, regulates nerve and muscle function, and builds bone, DNA, and protein. A lack of magnesium may also contribute to headaches and migraines.</span><span style="font-weight: 400;">Some people use magnesium to treat and prevent migraine symptoms, including a severe headache, visual disturbances, sensitivity to light and sound, and nausea and vomiting</span><i><span style="font-weight: 400;">Reference : By Bethany Cadman, Reviewed by Lindsay Slowiczek, PharmD,</span></i><i><span style="font-weight: 400;">https://www.medicalnewstoday.com/articles/322596.php</span></i><i><span style="font-weight: 400;"> , july 4</span></i><i><span style="font-weight: 400;">th</span></i><i><span style="font-weight: 400;">,2019</span></i>
" >Magnesium
[8]
citrate or glycinate
300 mg BIDGI cramps, diarrheaConstipationLoose bowel movements, cramps
Vitamin B2
(riboflavin)
400 mg dailyYellow/orange urineNoneNone
Coenzyme Q10100 mg TID or 300 qdGI upsetNoneNone
Butterbur
(Petadolex)
75 mg BIDGI (burping)AVOID
Liver toxicity concerns

Should NOT be first line, less frequently used, low evidence for efficacy but may be used in selected cases with significant Comorbidity
<span style="font-weight: 400;">Comorbidity is defined as the co-occurrence of one or more disorders in the same child or adolescent either at the same time or in some causal sequence. In relation to internalising disorders, data from clinical samples points to a high overlap between these disorders and substance use disorders, independent of whether the referred problem is a substance use.</span><i><span style="font-weight: 400;">Reference: </span></i><span style="font-weight: 400;">https://www.health.gov.au/internet/publications/publishing.nsf/Content/drugtreat-pubs-comorbid-toc~drugtreat-pubs-comorbid-4~drugtreat-pubs-comorbid-4-3</span> <i><span style="font-weight: 400;">, consulted on </span></i><span style="font-weight: 400;">july 1</span><span style="font-weight: 400;">st</span><span style="font-weight: 400;">,2019</span>
" >comorbidity
[9]
Verapamil
Isoptin
240 mg qdConstipation
Leg edema
AV block, fatigue
Hypertension
Angina
Constipation
Hypotension
Gabapentin
Neurontin
1200- 2400 daily (divided doses)Drowsiness
Dizziness
Weight gain 
Epilepsy
Neuropathic pain
Insomnia
Kidney failure (dose adjustment)
Venlafaxine
Effexor
150 -225 mg dailyNausea, vomiting, dry mouth, constipation
Nightmares
Drowsiness
Depression
Anxiety
Hypertension
Kidney failure
Valproic acid500 to 1000 mg BIDNausea, tremor, weight gain, hair loss, diarrhea, Dizziness
<span style="font-weight: 400;">Dizziness is a term used to describe a range of sensations, such as feeling faint, woozy, weak or unsteady. Dizziness that creates the false sense that you or your surroundings are spinning or moving is called vertigo.</span><i><span style="font-weight: 400;">Reference : By Mayo Clinic Staff,</span></i> <i><span style="font-weight: 400;">https://www.mayoclinic.org/diseases-conditions/dizziness/symptoms-causes/syc-20371787</span></i><i><span style="font-weight: 400;"> , </span></i><span style="font-weight: 400;">july 1</span><span style="font-weight: 400;">st</span><span style="font-weight: 400;">,2019</span>
" >dizziness
[5]
Liver toxicity
Parkinsonism
Teratogenicity
Epilepsy
Bipolar disease
Women of childbearing age

REFERENCES

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