From the Guidelines
For patients with migraines who cannot take beta blockers due to allergies, CGRP monoclonal antibodies such as erenumab, fremanezumab, and galcanezumab are recommended as first-line alternatives, as they have been shown to be effective in reducing migraine frequency and severity with fewer side effects 1. When considering alternative preventative medications, several options are available:
- Anticonvulsants: topiramate (starting at 25mg daily, gradually increasing to 50-100mg twice daily) and valproate (500-1000mg daily) are commonly prescribed first-line options.
- Calcium channel blockers: verapamil (120-360mg daily) can effectively reduce migraine frequency.
- Antidepressants: amitriptyline (10-150mg at bedtime) and venlafaxine (75-150mg daily) serve dual purposes for patients with comorbid depression or anxiety.
- CGRP monoclonal antibodies: erenumab (70-140mg monthly), fremanezumab (225mg monthly), and galcanezumab (120mg monthly after loading dose) represent newer options with fewer side effects.
- Botulinum toxin injections: (155-195 units every 12 weeks) work well for chronic migraines. These alternatives work through different mechanisms, including stabilizing neuronal membranes, modulating pain pathways, blocking pain signaling proteins, and preventing neurotransmitter release. Treatment choice should be individualized based on comorbidities, side effect profiles, and patient preferences, as recommended by the American College of Physicians 1 and the U.S. Department of Veterans Affairs and U.S. Department of Defense 1.
From the Research
Alternative Preventative Migraine Medications
For a patient with an allergy to beta blockers, several alternative preventative migraine medications can be considered. These include:
- Topiramate: a first-line agent for migraine prevention, as recommended by evidence-based guidelines 2, 3
- Amitriptyline: an effective and generally well-tolerated migraine prophylaxis therapy, with fair evidence of effectiveness 2, 3
- Divalproex/sodium valproate: a first-line agent for migraine prevention, with strong evidence of effectiveness 2, 3
- Gabapentin: a medication with fair evidence of effectiveness for migraine prevention 2, 3
- Botulinum toxin: a treatment with fair evidence of effectiveness, but further studies are needed to define its role in migraine prevention 2
- Candesartan: a medication with limited evidence of effectiveness, but can be considered in migraine prevention when other medications cannot be used 2, 3
- Magnesium: a supplement with limited evidence of effectiveness, but can be considered in migraine prevention when other medications cannot be used 2, 3
- Vitamin B2 (riboflavin): a supplement with limited evidence of effectiveness, but can be considered in migraine prevention when other medications cannot be used 2, 3
- Coenzyme Q10: a supplement with limited evidence of effectiveness, but can be considered in migraine prevention when other medications cannot be used 2, 3
Considerations for Topiramate
Topiramate is a commonly used medication for migraine prevention, with a strong evidence base to support its effectiveness 2, 3, 4, 5, 6. However, it can cause side effects such as paresthesia, fatigue, anorexia, nausea, taste alteration, and diarrhea. To minimize these side effects, clinicians can slowly increase the topiramate dose in small increments to allow habituation 6. Additionally, extended-release formulations of topiramate, such as Qudexy XR and Trokendi XR, may have a more favorable pharmacokinetic profile and reduce the risk of cognitive effects 6.