Would it be appropriate to switch a patient with abdominal migraines from Amitriptyline (Amitriptyline Hydrochloride) 150 mg daily to Propranolol (Propranolol Hydrochloride) 80 mg daily due to suspected medication-induced hyperhidrosis?

From the Guidelines

Switching from amitriptyline 150 mg daily to propranolol 80 mg daily for abdominal migraines is a reasonable approach in this case, given the patient's troublesome side effect of profuse sweating, as propranolol has been shown to be effective in migraine prevention with a more favorable side effect profile regarding sweating 1. The patient's current medication, amitriptyline, is known to cause anticholinergic side effects, including hyperhidrosis, which can disrupt normal thermoregulation and contribute to the sensation of overheating. Propranolol, a beta-blocker, is an effective alternative for migraine prophylaxis, with studies demonstrating its efficacy in preventing migraine headaches at doses ranging from 80 to 240 mg/d 1. Key considerations for the transition include:

• Gradually tapering off amitriptyline over 2-4 weeks to avoid withdrawal symptoms
• Simultaneously starting propranolol at a lower dose and titrating up to 80 mg daily over 1-2 weeks
• Monitoring for potential propranolol side effects, including bradycardia, hypotension, fatigue, and sleep disturbances
• Ruling out contraindications for propranolol, such as asthma, COPD, heart block, or bradycardia, before initiating therapy. If abdominal migraine symptoms worsen after the switch, alternative options like topiramate or calcium channel blockers could be considered, highlighting the importance of ongoing monitoring and adjustment of the treatment plan as needed.

From the Research

Switching to Propranolol for Abdominal Migraines

• The patient is currently managed with Amitriptyline HCl 150 mg daily for abdominal migraines but presents with ongoing complaints of profuse sweating, which she suspects may be contributed by the amitriptyline.
• Studies suggest that propranolol is a viable option for migraine prophylaxis, including abdominal migraines 2, 3, 4, 5.
• Propranolol has been shown to be effective in reducing the frequency of migraine attacks and is considered a first-line agent for migraine prevention 2, 3, 4.
• A study on abdominal migraine in adults found that patients responded to prophylactic migraine therapies, including β-blockers such as propranolol 6.
• Another study on abdominal migraine reported that 75% of patients treated with propranolol had an excellent response, with cessation of recurrent abdominal pain 5.
• However, it is essential to consider the potential side effects of propranolol, such as dizziness and fatigue, and weigh the benefits against the risks 4.
• The decision to switch to propranolol should be made after discussing the risks and benefits with the patient and considering their individual needs and medical history.

Dosage and Administration

• The proposed dosage of propranolol is 80 mg daily, which is within the recommended range for migraine prophylaxis.
• It is crucial to monitor the patient's response to the new medication and adjust the dosage as needed to minimize side effects and optimize efficacy.

Comparison with Amitriptyline

• Amitriptyline is also a first-line agent for migraine prevention, but it may be contributing to the patient's profuse sweating 2, 3, 4.
• The patient has reported some benefit from amitriptyline in managing their abdominal migraines, but the sweating has been a persistent issue.
• Switching to propranolol may help alleviate the sweating while maintaining or improving migraine control.