Topiramate (Topamax) is one of the most popular preventive drugs for migraine. This is not because it is more effective than other approved drugs. It is because it can cause weight loss. The drug manufacturer tried to get it approved for weight loss. The FDA, however, felt that while the side effects may be acceptable when treating epilepsy or migraines, they are not acceptable when treating obesity. You can argue that obesity is as serious a disorder but the FDA decision underscores the fact that the drug can have serious side effects.

Cognitive side effects can be obvious to most patients but for some, they are not. People begin to attribute their memory and word-finding difficulties to stress, lack of sleep, early-onset dementia, and other reasons. They have told me that they feel stupid on this drug, hence the moniker, Dopamax. Topiramate can also cause irritability, depression, fatigue, osteoporosis, glaucoma, and in 20%, kidney stones (10% with symptoms and 10% without). Like the other FDA-approved epilepsy drug, valproate, it is contraindicated in pregnancy because it can cause birth defects. I urge patients who are taking these drugs to be very vigilant about contraception.

In large clinical trials, 55% of patients had relief and were able to tolerate the drug. Postmarketing studies show that 40% of epilepsy patients stop the drug. Of these, one-fifth stop it because of lack of efficacy, almost half due to side effects, 12% due to both, and the rest for other reasons. It is likely that even a higher percentage of migraine patients stop the drug. Having an epileptic seizure is much more dangerous than having an attack of migraine.

The starting dose of topiramate is 25 mg nightly with a weekly increase of 25 mg up to 100 mg. Occasionally, patients benefit from a higher dose, up to 200 mg. If cognitive side effects are mild but bothersome, it may be worth trying a long-acting form of topiramate which can have fewer side effects. There are two such products on the market in the US – Qudexy and Trokendi. They are much more expensive than generic topiramate.

Topiramate is also approved for migraines in adolescents, ages 12 to 17. In this age group, it can cause or worsen an eating disorder.

Because of its side effects, topiramate is not one of the top choices of preventive drugs. The only time I move it up my list is when a patient is obese and is struggling to lose weight.

Tizanidine (Zanaflex) is a muscle relaxant that has been shown to relieve chronic migraines in a 200-patient double-blind study by Dr. Joel Saper and his colleagues. It may be particularly effective in people with neck and shoulder muscle spasm and pain. The majority of migraine sufferers have such muscle pains. It is also a good choice when you have insomnia along with migraines.

The main side effect of tizanidine is drowsiness and dizziness. This is why it is usually taken at night. The starting dose is 4 mg. It can be gradually increased to 8, and then 12 mg. In the double-blind study, the median dose was 18 mg. Some patients went up to 24 mg with 8 mg taken three times a day. Very few of my patients can take that much tizanidine during the day. At most, they will take 2-4 mg twice during the day and a higher dose at night.

Sumatriptan (Imitrex, Imigran) is by far the most popular triptan because it was the first one on the market. Because it came out a long time ago, many manufacturers make generic copies of this drug. This has reduced its price. Sumatriptan is available in combination with naproxen (Treximet). This combination is more effective than either drug alone.

The drug is available in 25, 50 and 100 mg strength. The starting dose for most patients is 100 mg. If after two hours one tablet has not relieved your migraine, take a second dose. In Europe, 50 mg tablets of sumatriptan have been sold without a prescription for over a decade.

The nasal spray of sumatriptan is not as effective as the tablets but the newer forms of nasal sumatriptan (Onzetra, Tosymra) are work better. However, the newer forms are much more expensive.

Sumatriptan injection is the most effective abortive migraine treatment. Over 80% of patients respond to it. Unfortunately, the injections are highly underutilized. The doctors are not very familiar with them, forget to offer them, and are afraid to prescribe them. The perception is that the side effects are common or they think that patients will not be receptive to the idea of injections.

The injection begins to work within 10-15 minutes and can quickly restore people to normal functioning. They are particularly useful for people for whom tablets are not likely to work well or work fast enough. People who wake up with a severe migraine, have a rapid onset of intense pain or have pronounced nausea or vomiting with their attacks.

Tightness in the jaw, neck, or chest is more common with the injection than with the tablet. This can be frightening but is not dangerous and is not related to the heart. This sensation usually subsides in about 15 minutes.

The injection is available in a vial and an easy-to-use autoinjector. Each shot contains 3 mg, 4 mg, or 6 mg of sumatriptan. The most effective dose for most people is 6 mg. If cost is an issue, sumatriptan is significantly cheaper in a vial than in an autoinjector. With the vial, you will also need a prescription for syringes..

Lamotrigine (Lamictal) is an epilepsy drug that is also approved as a mood stabilizer in bipolar disorders. Its exact mechanism of action is not well understood.

There are no good controlled trials of lamotrigine in migraines, but an open long-term study by European neurologists suggests that 100 mg of lamotrigine is effective not only in reducing the frequency of migraines but also in reducing the frequency and the duration of visual auras. There are also case reports of lamotrigine relieving complicated auras with visual and sensory symptoms.

The main side effects of lamotrigine are dizziness, drowsiness, upset stomach, and rash. The rash can be serious and in very rare cases fatal (Stevens-Johnson syndrome), but it could be avoided by starting with a very low dose (25 mg) and increasing it by 25 mg every two weeks. For epilepsy, the dose goes up to as high as 600 mg a day.