What is the role of Lyrica (pregabalin) in migraine treatment?

Role of Pregabalin (Lyrica) in Migraine Treatment

Pregabalin (Lyrica) is not included in standard guidelines as a first-line or recommended treatment for migraine but may be considered as an alternative preventive therapy in patients who have failed standard preventive treatments. 1, 2

Standard Migraine Treatment Guidelines

First-Line Acute Treatment

• NSAIDs are recommended as first-line therapy for most migraine sufferers, with evidence supporting aspirin, ibuprofen, naproxen sodium, and combination medications containing acetaminophen, aspirin, and caffeine 1, 2
• Acetaminophen alone lacks evidence for migraine treatment 1

Second-Line Acute Treatment

• Migraine-specific agents (triptans, DHE) are recommended when NSAIDs fail 1, 2
• Non-oral routes should be selected when nausea/vomiting are significant symptoms 1

First-Line Preventive Treatment

• Recommended first-line preventive agents include:
  • Propranolol (80-240 mg/day) 1
  • Timolol (20-30 mg/day) 1
  • Amitriptyline (30-150 mg/day) 1
  • Divalproex sodium (500-1500 mg/day) 1
  • Sodium valproate (800-1500 mg/day) 1

Evidence for Pregabalin in Migraine Prevention

Research Findings

• A small open-label study (n=47) found that pregabalin starting at 75 mg/day and titrated to 300 mg/day showed statistically significant reduction in migraine frequency after 1 and 3 months of treatment 3
• Another open-label study (n=30) demonstrated significant decreases in headache frequency, severity, rescue medication use, and headache impact scores with pregabalin treatment 4
• Patients with daily headache showed less response to pregabalin than those with non-daily headache 4
• A randomized controlled trial comparing pregabalin with propranolol for pediatric migraine prophylaxis found pregabalin more effective in reducing headache frequency 5

Adverse Effects

• Common side effects of pregabalin include:
  • Dizziness (40%) 4
  • Somnolence (29%) 4
  • Abnormal thinking (16.7%) 4
  • Constipation and fatigue (13.3%) 4
• In one study, 13% of patients reported side effects, with 6% discontinuing due to intolerable effects 3

Clinical Application

When to Consider Pregabalin

• Consider pregabalin for migraine prevention when:
  • Standard first-line preventive treatments have failed or are contraindicated 3, 4
  • Patient has comorbid conditions that might benefit from pregabalin (e.g., neuropathic pain, anxiety) 6
  • Frequency criteria for preventive therapy are met (≥2 attacks/month with significant disability) 1

Dosing Considerations

• Start at low dose (75 mg/day) and titrate gradually based on response and tolerability 3
• Effective doses in studies ranged from 150-300 mg/day 3, 4
• Greater frequency reduction was observed in patients who increased dosage within the first month of therapy 3

Important Caveats

• Evidence for pregabalin in migraine is limited to small, mostly open-label studies 3, 4
• Pregabalin is not FDA-approved for migraine prevention 7
• Sodium valproate is the only anticonvulsant with FDA approval specifically for migraine prevention 7
• Current guidelines do not include pregabalin among recommended preventive treatments 1, 2
• Medication overuse headache is a risk with frequent use of acute medications (>2 days/week) 1, 2