Preventive therapy of migraine.

Sir, I read with interest the recent report of acute myopia induced by topiramate used for migraine prophylaxis. I would like to make certain observations. Firstly, Bhattacharyya et al used two medications (flunarizine and topiramate) as the initial preventive treatment of migraine. However, the guidelines recommend usage of a single drug. The drug should be considered a failure only after an adequate trial (2-3 months) has been given. After the failure of the first drug, one has the option of using another drug or a two-drug combination. Also, Bhattacharyya et al have used two second-line agents for migraine prevention at the onset. However, guidelines recommend using a firstline agent initially, which include propranolol, divalproex sodium, sodium valproate and amitryptiline among others. Considering the fact that adverse effects are common with most of the drugs used for migraine prevention, one should be cautious in starting two second-line drugs as the first step. Secondly, the choice of agent should also be individualized depending on the patient profile. Bhattacharyya et al started flunarizine in an obese patient (on sibutramine for the same). Weight gain as a side effect of flunarizine is well known.