Medications for preventive treatment of migraine in adults: Comorbid factors for drug selection

Drug class (and examples)	Factors favoring use	Factors favoring avoidance
Beta blockers Atenolol Metoprolol Nadolol Propranolol	Hypertension* Cardiovascular disease (eg, HFrEF, MI within previous 3 years, atrial fibrillation, angina pectoris)	Bronchospastic disease Age >60 years Depression Fatigue Sexual dysfunction Tobacco use (diminished efficacy of propranolol)
Antidepressants Amitriptyline Venlafaxine	Depression Anxiety disorders Insomnia Neuropathic pain	Amitriptyline Suicidality (TCAs dangerous in overdose) Cardiovascular disease Anticholinergic effects (dry mouth, constipation, urinary retention, etc) Seizure disorder Glaucoma Venlafaxine Hypertension Seizure disorder Glaucoma
Antiseizure medications Topiramate Valproate	Seizure disorder Mood disorder (valproate) Obesity (topiramate)	Topiramate Weight loss Cognitive impairment Depression/mood problems Pregnancy (teratogen) Kidney stones Valproate Weight gain Diabetes/metabolic syndrome Menstrual irregularities Pregnancy (teratogen) Hair loss
CGRP antibodies/antagonists Erenumab Galcanezumab Fremanezumab Eptinezumab Rimegepant Atogepant	Monthly administration (some other CGRP antagonists can be administered once every 3 months)	Cardiovascular or cerebrovascular disease Pregnancy (limited safety information) Hypertension High cost

Several medications are available for preventive treatment of migraine. The selection of specific agent is individualized by factoring comorbid conditions, medication adverse effects, patient preferences, and cost. Refer to UpToDate for additional details.

CRGP: calcitonin gene-related peptide; HFrEF: heart failure with reduced ejection fraction; MI: myocardial infarction; TCAs: tricyclic antidepressants.

* Although beta blockers may provide modest benefit for lowering of blood pressure, they are not used for first-line treatment of primary hypertension absent a compelling indication. Refer to UpToDate review of drug therapy choice in primary hypertension.

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Medications for preventive treatment of migraine in adults: Comorbid factors for drug selection