Migraine: Preventive Treatment

Abstract

Migraine is a common episodic headache disorder. A comprehensive headache treatment plan includes acute attack treatment to relieve pain and impairment and long-term preventive therapy to reduce attack frequency, severity, and duration. Circumstances that might warrant preventive treatment include: (i) migraine that significantly interferes with the patient's daily routine despite acute treatment; (ii) failure, contraindication to, or troublesome side-effects from acute medications; (iii) overuse of acute medications; (iv) special circumstances, such as hemiplegic migraine; (v) very frequent headaches (more than two a week); or (vi) patient preference. Start the drug at a low dose. Give each treatment an adequate trial. Avoid interfering, overused, and contraindicated drugs. Re-evaluate therapy. Be sure that a woman of childbearing potential is aware of any potential risks. Involve patients in their care to maximize compliance. Consider co-morbidity. Choose a drug based on its proven efficacy, the patient's preferences and headache profile, the drug's side-effects, and the presence or absence of coexisting or co-morbid disease. Drugs that have documented high efficacy and mild to moderate adverse events (AEs) include beta-blockers, amitriptyline, and divalproex. Drugs that have lower documented efficacy and mild to moderate AEs include selective serotonin reuptake inhibitors (SSRIs), calcium channel antagonists, gabapentin, topiramate, riboflavin, and non-steroidal anti-inflammatory drugs.

Preventive treatment of migraine

“…The mechanism of action of β-blockers is not clear but it could occur by the inhibition of β 1 -mediated mechanisms [16]. β-Blockers, the most widely used class of prophylactic migraine drug, are ~50% effective at producing a >50% reduction in attack frequency and include propranolol, nadolol, atenolol, metoprolol and timolol [17].…”

“…In animal pain models, antidepressants potentiate the effects of co-administered opioids [16]. Amitriptyline (a tricyclic antidepressant) is the only antidepressant with consistent support for efficacy [17].…”

“…Perhaps it is their ability to block 5-HT release, interfere with neurovascular inflammation or interfere with the initiation and propagation of SD that is crucial [16]. The discovery that an abnormality in an a1A subunit (P/Q channel) can produce familial hemiplegic migraine has led to a search for more-fundamental associations [20].…”

Valproate semisodium ER for migraine and cluster headache prophylaxis

“…Some natural products, such as riboflavin, butterbur, and coenzyme Q10, appear effective for migraine prophylaxis. Due to its safety, magnesium is one option for pregnant women who require migraine prophylaxis [23][24][25][26]. Nevertheless, some preventive medications have been shown to be more efficacious than others in randomized, controlled trials.…”

Newer antiepileptic drugs: Possible uses in the treatment of neuropathic pain and migraine

“…At about the same time, many uncontrolled studies of the use of AEDs in the treatment of neuropathic pain, as well as a growing number of pilot studies and case series on the use of these agents in the prophylaxis of migraine, began to appear in the medical literature and in presentations at major national meetings. 13,14 These developments were accompanied by a large increase in the prescribing of gabapentin (and of AEDs released subsequently) for patients whose pain was refractory to the standard approaches.…”