What are the best management strategies for migraines in someone with a history of seizures?

Management of Migraines in Patients with a History of Seizures

For patients with a history of seizures, topiramate and divalproex sodium are the most appropriate first-line preventive medications for migraine management, as they effectively treat both conditions while reducing morbidity and mortality risks.

Acute Treatment Options

First-Line Treatment

• NSAIDs are recommended as first-line treatment for acute migraine attacks in most patients, including those with seizure history 1
• Specific effective options include:
  • Aspirin (650-1,000 mg every 4-6 hours) 1
  • Ibuprofen (400-800 mg every 6 hours) 1
  • Naproxen sodium (275-550 mg every 2-6 hours) 1
  • Acetaminophen-aspirin-caffeine combination 1
• Note that acetaminophen alone is ineffective for migraine treatment 1

Second-Line Treatment

• For moderate to severe migraines or those that don't respond to NSAIDs, migraine-specific medications should be considered 1
• However, caution is needed when selecting these medications for patients with seizure history:
  • Triptans (sumatriptan, rizatriptan, zolmitriptan, naratriptan) must be used with caution in patients with comorbidities 1
  • Triptans are most effective when taken early in an attack while headache is still mild 1
  • Avoid triptans in patients with uncontrolled hypertension, basilar or hemiplegic migraine 1

Special Considerations for Route of Administration

• Use non-oral routes of administration when nausea or vomiting are significant components of attacks 1
• Options include:
  • Sumatriptan subcutaneous injection for severe attacks or when oral medications aren't tolerated 1
  • Intranasal DHE has good evidence for efficacy and safety 1

Preventive Treatment for Patients with Seizure History

When to Consider Preventive Treatment

• Preventive therapy should be considered when:
  • Patient experiences two or more migraine attacks per month with disability lasting ≥3 days 1
  • Rescue medication is used more than twice weekly 1
  • Acute treatments fail or are contraindicated 1
  • Patient has uncommon migraine conditions (prolonged aura, migrainous infarction) 1

First-Line Preventive Options for Patients with Seizure History

• Antiepileptic medications are particularly beneficial for patients with comorbid seizures and migraines 2, 3
• Recommended options:
  • Topiramate (100-200 mg daily) - first-line option with strong evidence 2, 4, 5
  • Divalproex sodium (500-1,500 mg daily) - effective but with more side effects 1, 4

Mechanism and Benefits

• These medications work through multiple mechanisms including:
  • Sodium channel blockade affecting neural components of migraine pain 4
  • Reduction of neuronal hyperexcitability common to both conditions 2, 6
  • Modulation of glutamate, the main excitatory neurotransmitter involved in both disorders 6

Important Considerations and Monitoring

• For topiramate:

  • Start with low dose and gradually increase to minimize side effects 1
  • Monitor for cognitive effects, paresthesias, and weight loss 4
  • Contraindicated in pregnancy due to teratogenic risk 4

• For divalproex sodium:

  • May be particularly effective for patients with prolonged or atypical migraine aura 1
  • Monitor for hair loss, tremor, weight gain 1
  • Significant teratogenic risk (neural tube defects) - avoid in women of childbearing potential if possible 1, 4

• For both medications:

  • Allow 2-3 months for full clinical benefit to appear 1
  • Regular follow-up to assess efficacy and side effects 1

Lifestyle and Trigger Management

• Identify and avoid personal trigger factors when possible 1
• Common triggers include:
  • Alcohol, caffeine, foods containing tyramine or nitrates 1
  • Stress, fatigue, poor sleep quality 1
  • Environmental factors (perfumes, fumes, glare, flickering lights) 1
• Maintain regular sleep patterns and physical activity levels 1
• Use a headache diary to track attacks, triggers, and medication response 1

Cautions and Pitfalls

• Avoid medication overuse - limit acute treatments to no more than twice weekly 1
• Be vigilant for rebound headaches from overuse of:
  • Opiates, triptans, ergotamine 1
  • Analgesics containing caffeine, isometheptene, or butalbital 1
• Monitor for comorbid anxiety and depression, which occur at higher rates in patients with both migraine and epilepsy 6
• Consider the bidirectional relationship between seizures and headaches - some seizures may trigger headaches and vice versa 2, 6