What medications can be used to treat anxiety and migraines?

Medications for Dual Treatment of Anxiety and Migraine

For patients requiring treatment of both anxiety and migraine, amitriptyline is the first-line choice, as it has the strongest evidence for migraine prevention and effectively treats comorbid anxiety and depression. 1, 2, 3

Primary Recommendation: Amitriptyline

• Amitriptyline has the best evidence base for migraine prevention among all antidepressants and simultaneously treats anxiety disorders. 4, 3
• Start at 10-25 mg at bedtime and titrate up to 50-150 mg as tolerated for optimal efficacy in both conditions. 3
• The sedating effect provides additional benefit for patients with comorbid insomnia, which frequently accompanies both anxiety and migraine. 1, 3
• Recognition of psychiatric comorbidities is critical because they influence drug choice and can improve outcomes for both conditions when treated together. 1

Alternative Options When Amitriptyline Is Not Tolerated

SNRIs (Venlafaxine or Duloxetine)

• SNRIs are the most effective option for patients with comorbid depression/anxiety and migraine who cannot tolerate tricyclic antidepressants. 2, 3
• Venlafaxine and duloxetine have evidence for efficacy in both migraine prevention and anxiety disorders. 2, 3
• Critical pitfall: Counsel patients extensively about withdrawal effects from SNRIs, which can be substantial and require slow tapering. 3

Beta-Blockers (Propranolol or Timolol)

• Propranolol and timolol have sufficient evidence and consensus as first-line agents for migraine prevention. 4
• Beta-blockers may help when anxiety is present, particularly for physical anxiety symptoms. 2
• Propranolol is particularly useful for patients with performance anxiety or panic disorder with prominent physical symptoms. 2

Anticonvulsants for Specific Scenarios

• Divalproex sodium or topiramate are indicated for migraine without aura and have demonstrated efficacy in mood stabilization. 2
• Topiramate is preferred for patients with obesity due to its association with weight loss. 1
• Lamotrigine is specifically indicated for migraine with aura and has mood-stabilizing properties. 2
• Pregabalin has demonstrated efficacy in anxiety disorders and may be considered when other options fail. 2

Medications to Avoid

• SSRIs (including fluoxetine) are not effective for most migraine patients despite their efficacy in anxiety. 3
• Flunarizine has only limited evidence for migraine prevention and should not be first-line. 4
• Do not use medications that may worsen psychiatric comorbidity (specific agents depend on the anxiety subtype). 2

Treatment Algorithm

1. First-line: Start amitriptyline 10-25 mg at bedtime, titrate to 50-150 mg based on response and tolerability. 4, 3

2. If amitriptyline not tolerated: Switch to nortriptyline (better tolerated alternative tricyclic) or venlafaxine/duloxetine (SNRI). 3

3. If anxiety predominates with physical symptoms: Consider propranolol 80-240 mg daily (extended-release formulation). 4, 2

4. If obesity is present: Prioritize topiramate 50-200 mg daily. 1

5. If migraine with aura: Consider lamotrigine for dual mood stabilization and aura prevention. 2

6. Monitor for 2-3 months before declaring treatment failure, as preventive medications require adequate trial duration. 5

Critical Considerations

• Screen all patients with frequent episodic or chronic migraine for depression and anxiety before initiating treatment. 2
• The coexistence of psychiatric disorders alters quality of life, increases total disability, and increases the probability of evolution to chronic migraine. 2
• Limit acute migraine medications to no more than twice weekly to prevent medication-overuse headache, which is more common in patients with psychiatric comorbidity. 1, 5
• When specific treatment for severe anxiety is needed beyond migraine prevention, add cognitive behavioral therapy, which has good evidence of efficacy in anxiety disorders. 2