From the Guidelines
Antiepileptic medications, specifically divalproex sodium, are a recommended first-line option for migraine prophylaxis. According to the evidence from 1, divalproex sodium (500 to 1500 mg/d) is one of the recommended first-line agents for the prevention of migraine headache. The use of antiepileptic medications for migraine prophylaxis is supported by the fact that they can modulate neurotransmitters and stabilize neuronal membranes, thereby reducing cortical spreading depression that triggers migraines. Some key points to consider when using antiepileptic medications for migraine prophylaxis include:
- Starting with a low dose and gradually increasing to minimize side effects
- Monitoring liver function and drug levels, especially with valproate
- Avoiding use in pregnancy, particularly valproate due to teratogenicity
- Using cautiously in women of childbearing potential with appropriate contraception
- Continuing prophylactic treatment for at least 3-6 months before assessing effectiveness, with a 50% reduction in migraine frequency considered successful. Other antiepileptics, such as topiramate, gabapentin, and lamotrigine, may also be considered, but the evidence for their use is less robust compared to divalproex sodium 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Anti-Epileptic Drugs for Migraine Prophylaxis
- Topiramate is a first-line migraine preventive drug, effective in reducing headache frequency and improving quality of life 2, 3, 4
- The recommended initial target dose of topiramate is 100 mg per day, with no increase in efficacy observed between 100 and 200 mg per day 2, 3
- Common adverse events associated with topiramate include paresthesia, fatigue, decreased appetite, nausea, diarrhea, weight decrease, and taste perversion 2, 3, 4
- Other anti-epileptic drugs, such as valproate, gabapentin, and lamotrigine, may also be effective in migraine prophylaxis, but their use is limited by potential side effects and interactions 5, 6
- Carbamazepine and levetiracetam have shown promise in reducing headache frequency, but more studies are needed to confirm their efficacy and safety 6
Efficacy and Safety of Anti-Epileptic Drugs
- Topiramate has been shown to be effective in reducing headache frequency and improving quality of life in patients with episodic and chronic migraine 2, 3, 4
- Valproate is effective in migraine prophylaxis, but its use is limited by potential side effects, including teratogenicity and hepatotoxicity 5
- Gabapentin and lamotrigine may be effective in migraine prophylaxis, but their use is limited by potential side effects and interactions 5, 6
- Carbamazepine and levetiracetam have shown promise in reducing headache frequency, but more studies are needed to confirm their efficacy and safety 6
Clinical Considerations
- Topiramate should be used with caution in patients with a history of renal stones or metabolic acidosis, and patients should be counseled to maintain hydration 4
- Topiramate is associated with an increased risk of cleft lip with or without cleft palate in pregnancy, and its use should be avoided in pregnant women whenever possible 4
- Extended-release formulations of topiramate may be associated with fewer cognitive effects and improved adherence compared to immediate-release formulations 4