![]() desipramine*, nortriptyline* and protriptyline* are less sedative alternatives with no formal evidence of efficacy.These are most apparent in the first couple of weeks and usually settle with continued use Commonly reported adverse events include dry mouth, sedation, dizziness and nausea. except in the last case it is wise to explain the choice of this drug to patients who do not consider themselves depressed or they may reject it.amitriptyline* 10-150mg daily, at or 1-2 hours before bedtime, is first-line when migraine coexists with:.Commonly reported adverse events include cold extremities, reduced exercise tolerance and dizziness on the same basis plus the knowledge that once-daily dosing is associated with significantly better compliance, bisoprolol* 5 10mg od may be the beta-blocker of choice but better evidence of its efficacy is needed.Cardioselectivity and hydrophilicity both improve the side-effect profile on this basis, atenolol* 25-100mg bd is to be preferred over metoprolol 50-100mg bd and this over propranolol LA 80mg od-160mg bd beta-adrenergic blockers without partial agonism are first-line if not contraindicated by asthma, heart failure, peripheral vascular disease or depression.BASH guidance (3) suggests - note * denotes unlicensed indication.advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people.review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment.for people who are already having treatment with another form of prophylaxis, and whose migraine is well controlled, continue the current treatment as required.if both topiramate and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5-8 weeks according to the person's preference, comorbidities and risk of adverse events.do not offer gabapentin for the prophylactic treatment of migraine.amitriptyline is also an option for the prophylactic treatment of migraine according to the person's preference, comorbidities and risk of adverse events.Use caution when prescribing propranolol, in line with the Healthcare Safety Investigation Branch's report on the under-recognised risk of harm from propranolol People with depression and migraine could be at an increased risk of using propranolol for self-harm.In November 2015, this was an off-label use of topiramate in children and young people.Follow the MHRA safety advice on antiepileptic drugs in pregnancy.the importance of effective contraception for women and girls of childbearing potential who are taking topiramate (for example, by using medroxyprogesterone acetate depot injection, an intrauterine method or combined hormonal contraception with a barrier method).the risk of reduced effectiveness of hormonal contraceptives with topiramate.the risk of fetal malformations with topiramate.the potential benefit in reducing migraine recurrence and severity.for the prophylaxis of migraine, offer topiramate or propranolol after a full discussion of the benefits and risks of each option.topiramate or propranol are the suggested first line prophylactic agents.Also 5HT1 agonists can more effectively deal with many attacks than previous acute treatments. ![]() This is because prophylactic agents only have limited success and risk chronic side effects. Migraine recurring four or more times per month should be treated prophylactically (1). Identifying and avoiding trigger factors can reduce the frequency of migraine attacks by up to 50%. Respiratory and chest medicine chevron_right.Diabetes and endocrinology chevron_right.
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