What medication can be given to prevent migraines in a patient taking sumatriptan (Imigran) for acute migraine treatment?

Preventive Medications for Migraine in Patients Taking Sumatriptan

Beta-blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day), anticonvulsants (topiramate, valproate 500-1500 mg/day), and antidepressants (amitriptyline 30-150 mg/day) are the recommended first-line preventive medications for migraine in patients also taking sumatriptan for acute attacks. 1

First-Line Preventive Options

Beta-Blockers

• Propranolol (80-240 mg/day)
• Metoprolol
• Timolol (20-30 mg/day)

Beta-blockers are well-established preventive agents that can be safely used alongside sumatriptan for acute treatment. They work through different mechanisms, making them complementary to triptans.

Anticonvulsants

• Topiramate
• Divalproex sodium (500-1500 mg/day)
• Sodium valproate (800-1500 mg/day)

These medications have strong evidence for migraine prevention and do not interact with sumatriptan used for acute attacks.

Antidepressants

• Amitriptyline (30-150 mg/day)

Tricyclic antidepressants like amitriptyline are particularly useful when migraine coexists with depression, anxiety, or sleep disturbances.

Medication Selection Algorithm

1. Assess comorbidities:

   • If patient has anxiety → Consider amitriptyline
   • If patient has hypertension → Consider beta-blockers
   • If patient has epilepsy → Consider anticonvulsants

2. Consider contraindications:

   • Avoid beta-blockers in patients with asthma, bradycardia, or heart block
   • Avoid valproate in women of childbearing potential due to teratogenicity
   • Avoid amitriptyline in patients with cardiac conduction disorders or urinary retention

3. Start with lowest effective dose and titrate gradually to minimize side effects while achieving therapeutic benefit

Important Considerations

• Medication overuse: Monitor for medication overuse headache with frequent use of sumatriptan (>10 days/month) 1
• Timing: Preventive medications should be taken daily, while sumatriptan is reserved only for acute attacks
• Evaluation: Assess response to preventive treatment within 2-4 weeks of medication changes 1
• Ergot derivatives: Never combine sumatriptan with ergotamine derivatives due to risk of vasospasm 2, 3

Additional Non-Pharmacological Approaches

• Maintain regular sleep schedule
• Identify and avoid triggers through headache diary
• Implement stress management techniques
• Ensure regular hydration
• Consider cognitive-behavioral therapy, biofeedback, or relaxation training 1

When to Refer to Specialist

Consider referral to neurologist or headache specialist if:

• Headaches remain refractory to treatment
• Neurological symptoms accompany headaches
• Diagnostic uncertainty exists
• Headaches significantly impact quality of life despite management 1

Remember that sumatriptan is contraindicated in patients with ischemic heart disease, previous myocardial infarction, Prinzmetal's angina, and uncontrolled hypertension 3. When selecting a preventive medication, ensure it does not increase cardiovascular risk in patients who may already have limitations due to sumatriptan's contraindications.