Pharmacological Approaches to Managing Migraine and Associated Comorbidities—Clinical Considerations for Monotherapy Versus Polytherapy

Abstract

Comorbidity is defined as an illness that occurs more frequently in association with a specific disorder than would be found as a coincidental association in the general population. Conditions that are frequently comorbid with migraine include depression, anxiety, stroke, epilepsy, sleep disorders, and other pain disorders. In addition, many common illnesses occur concomitantly (at the same time) with migraine and influence the treatment choice. Migraine management, and especially migraine prevention, can be challenging when patients have comorbid or concomitant illnesses. The objectives of this initiative are to review the literature on managing patients who have migraine and common comorbidities, present additional clinical approaches for care of these difficult patients, and evaluate the areas in which research is needed to establish evidence-based guidelines for the management of migraine with associated comorbid conditions. Key words: migraine, polytherapy, monotherapy, comorbidity (Headache 2007;47:585-599) Migraine is a disorder that is present in approximately 13% of the general population and is associated with both comorbid and concomitant illnesses that influence treatment strategy.1,2 Comorbidity is defined as an illness that occurs more frequently in association with a specific disorder than that would be found as

Management of Stroke in Infants and Children

“…Options for prophylactic therapy include amitriptyline, sodium valproate, cyproheptadine, or a combination of short-acting verapamil hydrochloride or other calcium channel antagonists and aspirin if there are no contraindications. 203,204 No specific treatment is currently available for patients with CADASIL; antiplatelet agents may be tried.…”

Controversies in migraine: monotherapy

“…This situation has been defined as ''false polytherapy'' in a previously published paper on chronic migraine patients [26], and it may correspond in most cases to what Silberstein et al [25] defined as therapeutic independence in their review paper on pharmacological approaches to managing migraine and associated comorbidities. This approach is based on the prescription of two or more drugs to a given patient, each compound meant to treat each condition separately.…”

“…This approach may reduce the number of daily medications in a given patient, limiting possible adverse events, and enhancing patient's compliance and adherence to therapy. However, clinicians must be aware that the use a ''two-for-one'' strategy may have some risks, which have been systematically discussed by Silberstein et al [25]. The most common are the risk of treating only one condition; the risk of choosing suboptimal medications.…”

“…Many migraine patients have comorbid or coexisting conditions: epilepsy, colitis, essential tremor, sleep apnea syndrome, other chronic pain disorders, and, particularly psychiatric (depression, anxiety, bipolar disorder) and cardiovascular (hypertension, Raynaud's syndrome, angina, stroke) disorders [25]. Thus, a proportion of patients with migraine and concurrent medical problems may need two or more drugs.…”

Best Practices for Patients With Chronic Migraine

“…41 Drug selection should be individualized on the basis of the patient's overall medical profile, avoiding treatments that may exacerbate a comorbid condition (eg, flunarizine and b-blockers, which may potentially exacerbate depression). 7,42,43 However, patients with tachycardia or hypertension may find b-blockers helpful in treating the headache disorder and the comorbid cardiovascular disorder. 31 When a single agent does not sufficiently improve both the migraine and the comorbid disorder or is not well tolerated, polytherapy should be considered.…”