Is Largatil (Cyproheptadine) effective for treating hemiplegic migraines?

Treatment of Hemiplegic Migraines

Largatil (cyproheptadine) can be effective as a second-line preventive treatment for hemiplegic migraines, particularly in younger patients, with studies showing a 55.3% reduction in headache frequency. 1

First-Line Treatment Options for Hemiplegic Migraines

Preventive Treatments

According to current guidelines, the following should be considered as first-line preventive treatments for hemiplegic migraines:

• Beta-blockers (propranolol, metoprolol)
• Topiramate (50-100 mg daily)
• Candesartan 2

Acute Treatments

For acute management of hemiplegic migraine attacks:

• Acetaminophen
• NSAIDs (ibuprofen 400-600mg, naproxen sodium 500-550mg) 2, 3

Second-Line Preventive Options

If first-line treatments are ineffective or contraindicated, consider:

• Cyproheptadine (Largatil) - particularly effective in younger patients (mean age 8.8 years in studies), with 83% response rate and 55.3% reduction in headache frequency 1
• Flunarizine (5-10 mg once daily) - contraindicated in patients with parkinsonism or depression 4, 2
• Amitriptyline (10-100 mg at night) - contraindicated with heart failure, glaucoma, or when taking MAOIs or SSRIs 4, 2
• Sodium valproate (600-1,500 mg daily) - absolutely contraindicated in women of childbearing potential 4, 2

Third-Line Options

For refractory cases:

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) - recent evidence shows promising results specifically for hemiplegic migraine 5
• OnabotulinumtoxinA (155-195 units every 12 weeks) 4

Treatment Algorithm

1. Start with first-line preventive therapy (beta-blockers, topiramate, or candesartan) if experiencing ≥2 attacks per month or attacks are severe and disabling
2. Evaluate response after 2-3 months
3. If inadequate response:
   • Check for medication adherence and proper dosing
   • Consider switching to another first-line agent or adding a second-line agent like cyproheptadine (Largatil)
4. For acute attacks: Use acetaminophen or NSAIDs as first-line treatment

Important Considerations

• Unlike regular migraine, triptans remain controversial in hemiplegic migraine due to theoretical concerns about vasoconstriction, though some experts do prescribe them when common analgesics are insufficient 3
• Conventional cerebral angiography is contraindicated in hemiplegic migraine as it may provoke an attack 3
• Treatment adherence is a significant challenge - in studies of migraine preventives, almost half of patients (49.6%) modified their treatment regimen within 6 months, often without medical advice 6
• Side effects are the most common reason for discontinuation of preventive treatments (59.1% of cases) 6

Monitoring and Follow-up

• Use headache calendars to track frequency, intensity, and medication use
• Evaluate treatment response after 2-3 months
• If treatment is successful, continue for 6-12 months before attempting to taper to find minimum effective dose 2

Cyproheptadine (Largatil) has demonstrated good efficacy specifically in pediatric migraine prevention studies, making it a valuable option in the treatment arsenal for hemiplegic migraines, particularly for younger patients who may not tolerate other preventive medications.