From the Guidelines
The next best recommendation for migraine prevention in this patient would be to try candesartan or telmisartan, as suggested by the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1. Given that the patient is experiencing dizziness with topiramate after less than one week of use, this side effect suggests poor tolerability that may worsen with continued use or dose increases. The patient's current medication list, including citalopram, estradiol, progesterone, rizatriptan, topiramate, and trazodone, should be reviewed for potential interactions with the new preventive medication. Candesartan or telmisartan are recommended as first-line medications for the prevention of episodic migraine, with a strong recommendation based on recent evidence 1. Alternatively, propranolol could be considered, though it is suggested with a weak recommendation 1, and the patient should be screened for contraindications such as asthma, bradycardia, or heart block. The dizziness from topiramate could be due to its effects on carbonic anhydrase or neuronal inhibition, and these effects often persist or worsen with continued use. When switching medications, the topiramate should be tapered off gradually while the new preventive medication is initiated to avoid rebound headaches. It is also important to evaluate treatment responses shortly after initiation and regularly thereafter, assessing attack frequency, attack severity, and migraine-related disability, as recommended by the diagnosis and management of migraine in ten steps guideline 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Migraine Prevention Recommendations
The patient is experiencing dizziness after starting topiramate for migraine prevention. Considering the patient's current medication list and the side effects of topiramate, the next best recommendation for prevention of migraines can be explored.
- The patient is already taking topiramate, which is a first-line agent for migraine prevention, as recommended by studies 2, 3.
- However, due to the patient's experience of dizziness, alternative options can be considered.
- Other first-line agents for migraine prevention include propranolol, timolol, amitriptyline, divalproex, and sodium valproate, as suggested by studies 2, 3.
- Gabapentin and naproxen sodium have also shown fair evidence of effectiveness in migraine prevention 2.
- Botulinum toxin has demonstrated fair effectiveness, but further studies are needed to define its role in migraine prevention 2.
- The choice of preventive treatment should be based on the presence of comorbid and coexistent illness, patient preference, reproductive potential and planning, and best available evidence 3.
- In the case of topiramate, its efficacy in reducing migraine frequency and acute medication use, improving quality of life, and reducing disability in patients with episodic migraine and chronic migraine has been established 4.
- However, the patient's experience of dizziness may be a common side effect of topiramate, and the dose may need to be adjusted or an alternative medication considered.
Alternative Treatment Options
Considering the patient's current medication list and the side effects of topiramate, alternative treatment options can be explored.
- Propranolol, a beta-blocker, is a first-line agent for migraine prevention and may be considered as an alternative to topiramate 2, 3.
- Amitriptyline, an antidepressant, is also a first-line agent for migraine prevention and may be considered as an alternative to topiramate 2, 3.
- Gabapentin, an antiepileptic, has shown fair evidence of effectiveness in migraine prevention and may be considered as an alternative to topiramate 2.
- The CGRP monoclonal antibodies are newer options for migraine prevention and may be considered as an alternative to topiramate 5.