Antiseizure medications for the prophylaxis of migraine during the anti-CGRP drugs era

: Migraine and epilepsy are fundamentally distinct disorders that can frequently coexist in the same patient. These two conditions have significant differences in diagnosis and therapy but share some widely-used preventive treatments. Antiseizure medications (ASMs) are the mainstay of therapy for epilepsy and about thirty different ASMs are available to date. ASMs are widely prescribed for other neurological and non-neurological conditions, including migraine. However, only topiramate and valproic acid/valproate currently have an indication for migraine prophylaxis that is supported by high-quality evidence. Although without specific approved indications, and with a low level of evidence or recommendation, several other ASMs are used for migraine prophylaxis. Understanding ASM antimigraine mechanisms, including their ability to affect the pro-migraine calcitonin gene-related peptide (CGRP) signaling pathway and other pathways, may be instrumental in identifying the specific targets of their antimigraine efficacy and may increase awareness of the neurobiological differences between epilepsy and migraine. Several new ASMs are under clinical testing or have been approved for epilepsy in recent years, providing novel potential drugs for migraine prevention to enrich the treatment armamentarium along with drugs that inhibit the CGRP pathway.