Can gabapentin (anticonvulsant) be used to treat migraines?

Gabapentin for Migraine Treatment

Gabapentin should not be used for the prevention of episodic migraine as current evidence suggests it is ineffective and may cause adverse events. 1

Evidence Against Gabapentin for Migraine Prevention

• The 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline specifically recommends against the use of gabapentin for the prevention of episodic migraine (weak against recommendation) 1
• A Cochrane systematic review concluded that gabapentin is not efficacious for migraine prophylaxis in adults and should not be used in routine clinical practice due to common adverse events 2
• Adverse events commonly reported with gabapentin include dizziness, somnolence, fatigue, and ataxia 3

Recommended First-Line Treatments for Migraine

For Acute Treatment of Migraine:

• Strong recommendation for triptans (eletriptan, frovatriptan, rizatriptan, sumatriptan, zolmitriptan) or combination of sumatriptan and naproxen 1
• Strong recommendation for aspirin-acetaminophen-caffeine combination 1
• Weak recommendation for simple analgesics like acetaminophen, aspirin, ibuprofen, or naproxen 1
• Weak recommendation for newer CGRP antagonists (rimegepant, ubrogepant) 1

For Migraine Prevention:

• Strong recommendation for candesartan or telmisartan 1
• Strong recommendation for CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1
• Weak recommendation for several options including:
  • Topiramate 1
  • Propranolol 1
  • Valproate 1
  • Lisinopril 1
  • Oral magnesium 1
  • OnabotulinumtoxinA (for chronic migraine only) 1

Treatment Selection Algorithm

1. Determine migraine pattern:

   • Episodic (less than 15 headache days per month) 1
   • Chronic (15 or more headache days per month) 1

2. For acute treatment:

   • Mild to moderate attacks: NSAIDs or combination analgesics containing caffeine 1
   • Moderate to severe attacks: Triptans or combination therapies 1
   • For attacks with significant nausea/vomiting: Consider non-oral routes of administration 1

3. For preventive treatment (when indicated):

   • Consider prevention if patient has:
     • Two or more attacks per month with disability lasting 3+ days 1
     • Contraindication to or failure of acute treatments 1
     • Use of acute medications more than twice weekly 1
     • Presence of uncommon migraine conditions 1
   • First-line options (avoid gabapentin):
     • CGRP monoclonal antibodies 1
     • Candesartan or telmisartan 1
     • Beta-blockers (propranolol, timolol) 1
     • Anticonvulsants (topiramate, valproate - NOT gabapentin) 1

Important Considerations and Pitfalls

• Limit use of acute medications to avoid medication overuse headache (simple analgesics <15 days/month, triptans <10 days/month) 1
• Monitor for adverse effects, especially with preventive medications that require long-term use 1
• While some older, smaller studies suggested gabapentin might be effective 3, 4, 5, more rigorous and recent evidence contradicts these findings 1, 2
• The most recent and highest quality evidence (2023 VA/DoD guidelines) specifically recommends against gabapentin for migraine prevention 1

Special Populations

• For patients with both migraine and tension-type headache, amitriptyline may be more effective than beta-blockers 1
• For chronic migraine, consider onabotulinumtoxinA injections 1
• For patients with contraindications to first-line treatments, consider non-pharmacological approaches such as biofeedback, cognitive-behavioral therapy, or exercise 1