What is the next best option for a 52-year-old female with migraines who was taking Trazodone (trazodone), Celexa (citalopram) and Amitriptyline (amitriptyline) but discontinued Amitriptyline and started on Topamax (topiramate), now intolerant to Topamax?

From the Guidelines

For a 52-year-old female with migraines who cannot tolerate topiramate (Topamax) while on trazodone and Celexa, valproate would be the next best option, as it has a "weak for" recommendation for the prevention of both episodic and chronic migraines, with a statistically significant reduction in monthly migraine days 1. Consider starting at 500 mg daily and titrating up to 1000 mg daily as needed and tolerated. Valproate modulates GABA neurotransmission, which contributes to its efficacy in migraine prevention. Other reasonable alternatives include:

• CGRP monoclonal antibodies, such as erenumab, fremanezumab, or galcanezumab, which have a "strong for" recommendation for the prevention of episodic and chronic migraines, with a statistically significant reduction in mean monthly migraine days 1.
• Atogepant, which has a "weak for" recommendation for the prevention of episodic migraines, with a statistically significant reduction in monthly migraine days 1.
• Eptinezumab, which has a "weak for" recommendation for the prevention of episodic and chronic migraines, with a statistically significant reduction in mean monthly migraine days 1. Since she previously took amitriptyline, another option would be to try a different tricyclic antidepressant like nortriptyline, which often has fewer side effects. Monitor for potential drug interactions, particularly with the combination of valproate and trazodone, and adjust the treatment plan accordingly. It is also essential to consider non-pharmacologic therapies, such as aerobic exercise or physical therapy, which have a "weak for" recommendation for the prevention of migraines and tension-type headaches, as they can be beneficial in reducing headache frequency and intensity 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Alternative Treatment Options

Given the patient's intolerance to Topamax, alternative treatment options for migraine prevention can be considered.

• Valproate is an effective option for the preventive treatment of migraine, as shown in studies 2, 3, 4.
• Gabapentin or lamotrigine may have a role in the treatment of those with allodynia or frequent aura, respectively 2.
• Other medications such as oxcarbazepine, carbamazepine, and phenytoin may alleviate pain in trigeminal neuralgia, but their use in migraine prevention is less clear 2.

Antidepressants as Migraine Preventives

Antidepressants are commonly used as migraine preventives, and some have shown efficacy in clinical trials.

• Amitriptyline has the best evidence for use in migraine prevention, but the patient was already taking this medication and discontinued it 5.
• Nortriptyline is an alternative in patients who may not tolerate amitriptyline, and SNRIs including venlafaxine and duloxetine also have evidence for efficacy 5.
• SSRIs, including fluoxetine, are not effective for most patients 5.

Considerations for Next Best Option

When selecting the next best option, considerations should include the patient's medical history, comorbidities, and potential side effects of the medication.

• The patient is currently taking trazadone and Celexa, so potential interactions with these medications should be considered.
• The patient's intolerance to Topamax should be taken into account, and medications with similar side effect profiles may be avoided.