Gabapentin for Headaches
Gabapentin has established efficacy for migraine prophylaxis at 2400 mg/day but is not recommended for acute migraine treatment and has limited evidence for other headache types.
Migraine Prophylaxis: Primary Indication
Gabapentin is effective for preventing migraine attacks when titrated to 2400 mg/day, reducing migraine frequency by approximately 35% compared to placebo. 1
Evidence for Migraine Prevention
- A randomized controlled trial demonstrated that gabapentin 2400 mg/day reduced the median 4-week migraine rate from 4.2 to 2.7 attacks (compared to 4.1 to 3.5 with placebo, P=0.006) 1
- 46% of patients achieved at least 50% reduction in migraine frequency on gabapentin versus only 16% on placebo 1
- Limited evidence suggests only modest efficacy for migraine prevention, with gabapentin not being a first-line agent 2
Dosing Algorithm for Migraine Prevention
- Start: 300 mg at bedtime or 100-300 mg three times daily 2
- Titration: Increase by 100-300 mg every 1-7 days as tolerated 2
- Target dose: 2400 mg/day (800 mg three times daily) for optimal efficacy 1
- Trial duration: Allow 6-8 weeks total, including at least 2 weeks at maximum tolerated dose 2
- Renal adjustment: Reduce dose in patients with impaired renal function 2
Common Pitfalls
- Underdosing is the most common error—most clinical practice uses much lower doses than the 2400-3600 mg/day studied in trials 2
- Gabapentin has nonlinear pharmacokinetics due to saturable absorption, requiring careful titration 2
- Premature discontinuation due to initial dizziness and somnolence, which are typically transient 1
Acute Migraine Treatment: Not Recommended
Gabapentin has no role in treating acute migraine attacks. 2
- Guidelines for acute migraine management do not include gabapentin among recommended therapies 2
- Acute treatment should focus on NSAIDs, triptans, or combination analgesics depending on severity 2
Other Headache Types: Limited Evidence
Cluster Headache Prophylaxis
- An observational study (n=14) showed 44.9% reduction in headache frequency with gabapentin 900-2400 mg/day 3
- Response occurred within 1-2 weeks, with 50% pain reduction in 57% of patients 3
- However, this is low-quality evidence from a small, uncontrolled study and should not guide primary treatment decisions 3
Post-Dural Puncture Headache
- Case series (n=17) suggested potential benefit when other treatments failed 4
- This represents anecdotal evidence only and gabapentin is not a standard treatment for this condition 4
Neuropathic Head and Neck Pain
- Small case series (n=10) showed effectiveness for neuropathic pain in the head/neck region with doses up to 2400 mg/day 5
- Gabapentin is well-established for neuropathic pain conditions generally, binding to α2δ-1 subunits of voltage-gated calcium channels 2, 6
- If headache has neuropathic features (burning, lancinating pain, allodynia), gabapentin may be appropriate 5
Safety Profile
Common Adverse Effects
- Dizziness, somnolence, and peripheral edema are most frequent 2, 1
- Asthenia and infection also commonly reported 1
- 13-16% discontinuation rate due to adverse events in trials 1
- Side effects are typically mild to moderate and dose-dependent 2
Important Contraindications
- Requires dose adjustment for renal insufficiency based on creatinine clearance 2
- Few significant drug interactions compared to other anticonvulsants 2
Positioning in Treatment Algorithm
Gabapentin is not a first-line agent for migraine prophylaxis. 2
Preferred First-Line Agents
- Beta-blockers (propranolol, metoprolol) 2
- Tricyclic antidepressants (amitriptyline) 2
- Anticonvulsants (divalproex sodium, topiramate) 2
- Candesartan (strong guideline support from 2024 VA/DoD guidelines) 7