Which statement describes second-line migraine prophylaxis?

• A. TCAs and calcium channel blockers
• B. Anticonvulsants and beta-blockers
• C. NSAIDs and triptans
• D. Antidepressants and antipsychotics

Answer: (D)

Second-line migraine prophylaxis refers to meds used after first-line options are inadequate or not tolerated. Antidepressants, particularly tricyclics like amitriptyline, help prevent migraines by modulating central pain pathways through serotonin and norepinephrine systems and can also improve sleep, a common trigger factor. Antipsychotics have been used in refractory cases because their dopamine and serotonin antagonism can reduce central sensitization and help with associated symptoms, though they carry more side effects and are not preferred as first-line due to risk-benefit concerns. In contrast, NSAIDs and triptans treat acute attacks, not prevention, and first-line prophylaxis typically includes agents like beta-blockers or anticonvulsants. So, antidepressants and antipsychotics describe second-line prophylaxis.