Cardiac Arrhythmias, Heart Block, Bradycardia
ÎCaution should be taken in using tricyclics in patients with cardiac arrhythmia, or verapamil in patients with a heart block. Propranolol and other beta-blockers should be avoided in patients with bradycardia.
Depression
ÎPropranolol and other beta-blockers may exacerbate depression. Caution should be exercised in use of selective serotonin reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI) agents as well as some AEDs, especially in teenagers, because these agents may exacerbate depression or be related to suicidality.
Cognitive Impairment
ÎTopiramate should be avoided in subjects with cognitive concerns. Epilepsy
ÎTopiramate, valproic acid, and gabapentin may be preferred options in migraineurs with coexisting epilepsy.
Hypotension and Hypertension
ÎUse of beta-blockers, angiotensin-converting-enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers raises concern in patients with hypotension, which is not uncommon in young women with migraine. ARBs, beta-blockers, and calcium channel blockers are particularly attractive with coexistent hypertension. ACE inhibitors and ARBs may be especially beneficial in those with diabetes mellitus and renal disease.
Obesity
ÎCaution should be taken in using valproic acid, tricyclic antidepressants, cyproheptadine, and gabapentin, since they may contribute to additional weight gain.
Glaucoma
ÎRarely, patients taking topiramate have developed acute angle-closure glaucoma.
Renal Stones
ÎTopiramate should be avoided in migraineurs with oxalate or phosphate kidney stones.
Pregnancy
ÎValproic acid and ARBs should not be used if there is a potential for pregnancy. This is of particular concern because the majority of migraineurs are younger women of childbearing age. In general, all drugs used for prevention should be avoided in those for whom pregnancy is planned or anticipated.
Stroke
ÎARBs might offer benefits in terms of secondary stroke prevention for patients with migraine.
