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Clinician’s Corner: Migraine Prevention for Patients with Other Conditions

Depression TCA, SSRI, SNRI Beta-blockers
Bi-Polar disorder Valproate, Topiramate TCA, SSRI, SNRI
Anxiety TCA, SNRI, BB
Sleep disturbances TCA BB
Stroke Aspirin Ergot
Fibromyalgia TCA, SSRI, SNRI BB
Obesity Topiramate, SNRI TCA, Valproate, SSRI
Epilepsy Topiramate, Valproate, TCA SSRI, SNRI
Raynauds CCB, BB, Ergots
Over Age 60 BB (due to stroke risk)
Smokers BB (due to stroke risk)
Uninsured patients CGRP blockers $$$
Pregnancy Caution with all therapies. CCB seem to be safest Topiramate, Valproate

TCA= Tricyclic Antidepressants such as Amitriptyline (Elavil) and Nortriptyline (Pamelor)

SSRI= Selective Serotonin Reuptake Inhibitors such as fluoxetine (Prozac), sertraline (Zoloft)

SNRI= Serotonin-norepinephrine reuptake Inhibitor such as venlafaxine (Effexor), duloxetine (Cymbalta)

BB= Beta blockers such as metoprolol (Toprol-XL, Lopressor) and propranolol (Inderal)

CCB=Calcium Channel Blockers such as verapamil (Isoptin®)

CGRP= Calcitonin gene-related peptide blockers such as Ajovy®, Aimovig®, Emgality®


Evidence based guidelines adopted by the AAFP, AAN

  • NSAIDS as FIRST LINE Therapy
  • Triptans (or Dihydroergotamine???) indicated for those who fail to tolerate or respond to NSAIDS
  • NO evidence to support the use of butalbital compounds (Fioricet)
  • Little evidence to support use of isometheptene compounds (Midrin)
  • Opioids reserved for use when other medications cannot be used. (Cardio patients)

Remember when prescribing:

  • Drug overuse is a problem with sub-optimal therapy. Best to use the “one and done” approach.  Think of using only Sumatriptan 100mg or Rizatriptan 10mg, rather than redosing with a lower strength.
  • Don’t take acute drugs more frequently than 5 half lives. Sumatriptan and Rizatriptan’s half-life is 2.5 hours.


  • How often do you experience a headache of any severity per month?
  • How often do you experience severe or disabling headaches per month?
  • Has there been any change in either of these headaches over the past six months?
  • How often do you take Rx or OTC meds per month?
  • Questions that don’t work:
  • How many migraines per month?
  • On a scale of 1-10 how severe?

Your Thompson Pharmacist is an excellent resource in helping your physician select appropriate treatment and prevention for your disabling migraine headaches. We can help your physician come up with therapies that are compatible with your other medical conditions.  From the chart listed above, there are therapies that cost from $10 to $700!

Even for those high-priced treatment options, your Thompson can help you navigate through the drug company coupons and help you manage your headaches and your wallet!  Go Ahead and Ask… at Thompson Pharmacy it’s All for YOU!