Valproic acid for migraines isn’t generally the first line prophylactic agent as there are a few other agents that can be utilized.   There are also other indications for valproic acid like bipolar disorder, and seizures.

When using valproic acid for migraines there are definitely a few things to think about clinically.

1. Valproic acid is probably not a first choice and this especially goes for younger females of child bearing age. It definitely has some potential risks in pregnancy and this is the reason for avoidance in patients who may become pregnant or are planning to get pregnant at some point.
2. Drug levels are common in seizure disorder and bipolar disorder. When using valproic acid for migraines, we tend not to worry about this quite as much unless the patient is showing signs/symptoms of toxicity.
3. Valproic acid is used for migraine prophylaxis, it is not meant to used as an abortive agent. I have seen it tried PRN before without much benefit.
4. Lab monitoring is going to be important with valproic as it has some potential unique side effects. Liver function should be monitored as well as periodic CBC with platelets. Valproic acid does have a boxed warning on hepatotoxicity. In rare situations, I have seen valproic acid cause elevated ammonia levels as well.  Keep an eye out for CNS changes are consider checking an ammonia level if there is problems with confusion, sedation, or delirium type symptoms. Here’s an additional case scenario where VPA contributed to elevated ammonia levels.

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