Beta blockers (e.g., propranolol, metoprolol)	Good option for patients with hypertension, angina, or ischemic heart disease; the most commonly used drug class for migraine prevention. Adverse effects: Depression, erectile dysfunction, fatigue, lethargy, nightmares; monitor for bradycardia and hypotension. Avoid use in patients with asthma, atrioventricular conduction defects, bradycardia, and chronic obstructive pulmonary disease. Dosing: Start low and monitor heart rate and blood pressure.
Amitriptyline	Good option for patients with depression or insomnia; an effective drug class, but it has the highest risk of adverse effects. Adverse effects: Sedation and dose-related anticholinergic adverse effects are most common (blurry vision, constipation, dry mouth, palpitations, tachycardia, urinary retention); cardiac conduction abnormalities, orthostatic hypotension, QT prolongation, and weight gain can also occur. Avoid use in older patients or in patients with benign prostatic hypertrophy, glaucoma, or seizure disorder (lowers seizure threshold); use caution when prescribing to patients with cardiac disease. Dosing: Start with low dose at bedtime; patients with comorbid depression may eventually require higher doses to treat the depression.
Venlafaxine	Good option for patients with comorbid depression or anxiety. Adverse effects: Nausea and vomiting are common. Avoid use in patients with uncontrolled hypertension because it may increase blood pressure. Dosing: When discontinuing, taper slowly to avoid withdrawal symptoms.
Divalproex (Depakote)	Good option for patients with seizure disorder or bipolar disorder. Adverse effects: Gastrointestinal distress, nausea, somnolence, and vomiting are most common. Tremors and alopecia can occur later in course of therapy. Risk for liver failure, pancreatitis, and thrombocytopenia warrants periodic laboratory monitoring. Consider monitoring valproic acid levels if nonadherence is suspected. Avoid use in patients who are pregnant (risk for neural tube defects) or who have liver disease. Dosing: Start at 250 to 500 mg per day; monitor valproic acid levels if adherence is a concern.
Topiramate (Topamax)	Good option for patients with seizure disorder. Adverse effects: Paresthesia is most common. Abdominal pain, fatigue, impaired memory and concentration, kidney stones, nausea, taste changes, vomiting, and weight loss are also common. Although rare, because of risk for acute myopia and angle-closure glaucoma, monitor for eye pain. Risk for hepatotoxicity and metabolic acidosis warrants periodic laboratory monitoring. Avoid use in patients who are pregnant (risk for oral clefts) or who have glaucoma, kidney stones, or liver disease. Dosing: Increase 15 to 25 mg per week to reach 50 to 100 mg. May increase further if needed. Doses > 200 mg may reduce the effectiveness of oral contraceptives.