The role of the neuromodulators in the preventive treatment of migraine

INTRODUCTION: More than one quarter of patients who consult due to migraine need preventive treatment. At least half of these patients do not respond or cannot tolerate classical preventatives: beta-blockers, flunarizine or amitriptyline. AIM: To analyse the role of new antiepileptics (neuromodulators) in migraine prevention. DEVELOPMENT: Critical review of clinical trials carried out with antiepileptics for the treatment of migraine. Topiramate has demonstrated clear efficacy in the prevention of migraine with and without aura, including chronic migraine with and without analgesic overuse, although it is not tolerated by one fifth of patients. Valproic acid also has a demonstrated efficacy in the preventive treatment of migraine with and without aura, but its tolerability profile and the possibility of serious adverse events oblige us to prescribe this neuromodulator for refractory patients. Gabapentin shows a mild efficacy, clearly lower than that of topiramate and valproate. Lamotrigine is the treatment of choice in the prevention of migraine aura, but is not efficacious in the treatment of headache. Levetiracetam has shown some efficacy in open studies in migraine prevention, both in adults and children. Zonisamide has demonstrated good efficacy and tolerability in patients refractory to topiramate and shows a prolonged half life, which improves compliance. The remaining antipileptics have not shown efficacy. CONCLUSIONS: Topiramate and valproic acid have demonstrated efficacy in migraine prevention. Lamotrigine is efficacious for the treatment of migraine aura. Even though new studies are necessary, zonisamide could be a good option for the preventive treatment of migraine.