Episodic migraine headache prophylaxis

Background

Episodic migraine headache, defined as a migraine occurring less than 15 times a month, is a common malady affecting approximately 17% of women and 6% of men. The American Academy of Neurology published updated guidelines earlier this year to assist physicians in providing effective prophylaxis against episodic migraine headaches.

Conclusions

Prophylactic therapy is deemed necessary for patients with frequent headaches (more than four a month), long-lasting headaches (longer than 12 hours), or headaches causing a significant amount of physical disability.

The AAN estimates that 38% of people who suffer from migraine headaches meet criteria for preventative therapy, but only 3%-13% of these patients pursue or use it.

The goals of prophylactic treatment are to safely and effectively provide pharmacologic treatment to decrease headache frequency, reduce the number of migraine days, and reduce headache severity.

The antiepileptic drugs divalproex sodium, sodium valproate, and topiramate have been evaluated in multiple Class I studies showing efficacy for prevention of migraine headaches. Long-term use of divalproex sodium has been associated with weight gain in multiple trials. As many as 15% of patients treated with topiramate in one study had adverse effects, including paresthesias, weight loss, and somnolence.

Beta-blockers including metoprolol, propranolol, timolol, atenolol, and nadolol also have been found effective for migraine headache prevention.

The antidepressant medications amitriptyline and venlafaxine have been found to be as efficacious as topiramate for prophylaxis, and should be considered for migraine prevention as well.

Frovatriptan used for short periods surrounding menstrual cycles to prevent menstrual-associated migraines has been shown to be effective.

A literature review has found evidence against the use of the following medications for prevention of migraine: lamotrigine, clomipramine, acebutolol, clonazepam, nabumetone, oxcarbazepine, montelukast, and telmisartan.

Evidence for the use of fluoxetine and calcium-channel blockers has previously been considered adequate; but this most recent review found insufficient data to make firm conclusions about benefits.

Lisinopril and candesartan were evaluated by a single study suggesting possible benefit in migraine prophylaxis; but at present, these remain Class C recommendations.

A second recent AAN guideline reviewed nonsteroidal anti-inflammatory drugs (NSAIDs) and a number of herbal preparations for migraine prevention, and found evidence of benefit for petasites (Butterbur extract) and less evidence for riboflavin, NSAIDs, magnesium, and other herbal therapies.

The AAN states that the lack of evidence to support a recommendation for a medication not listed above should not undervalue the clinician’s prior experience with a particular medication or class of medication when choosing a migraine prophylaxis regimen.

Implementation

Migraine headaches pose a significant burden to patients seen in the primary care setting, and many patients could benefit from attempted medical prophylaxis.

The medications listed above represent either Class A or Class B recommendations per the AAN 2012 guidelines, as well as those found to be ineffective.

The use of a particular medication or class of medications should be based on individual patient needs and comorbidities.

Women of childbearing age make up a large percentage of patients who may benefit from migraine prophylaxis. Medications with known teratogenicity, such as valproic acid, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers should be avoided in this group. The AAN specifically recommends against pharmacologic therapy for prophylaxis in patients for whom pregnancy is planned or anticipated.

Some evidence has been found for the use of NSAIDs for migraine prophylaxis; but this class of medications is not currently recommended, given the potential adverse effects with chronic NSAID use.

Studies show evidence for the use and benefit of a number of complementary products. But the lack of data regarding dosing strategies and interaction with pharmacologic agents, as well as the unregulated nature of these products, makes their use challenging in clinical practice.

The use of triptans for menstrual-associated migraines has not been approved by the FDA, because the question remains unanswered whether the benefit demonstrated in trials is clinically meaningful.

References

• Silberstein S.D., et al. Pharmacologic treatment for episodic migraine in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. (Neurology 2012;78;1337-45).

• Holland S., et al. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. (Neurology 2012;78;1346-53).

Dr. Vancil is an assistant professor of internal medicine at the University of Arkansas, Little Rock. Dr. Golden is medical director of Arkansas Medicaid and professor of medicine and public health at the University of Arkansas. Dr. Hopkins is director of the division of general internal medicine at the University of Arkansas. E-mail them at imnews@elsevier.com. They reported having no relevant financial conflicts. This column, "The Effective Physician," appears regularly in Internal Medicine News.

Background

Episodic migraine headache, defined as a migraine occurring less than 15 times a month, is a common malady affecting approximately 17% of women and 6% of men. The American Academy of Neurology published updated guidelines earlier this year to assist physicians in providing effective prophylaxis against episodic migraine headaches.

Conclusions

Prophylactic therapy is deemed necessary for patients with frequent headaches (more than four a month), long-lasting headaches (longer than 12 hours), or headaches causing a significant amount of physical disability.

The AAN estimates that 38% of people who suffer from migraine headaches meet criteria for preventative therapy, but only 3%-13% of these patients pursue or use it.

The goals of prophylactic treatment are to safely and effectively provide pharmacologic treatment to decrease headache frequency, reduce the number of migraine days, and reduce headache severity.

The antiepileptic drugs divalproex sodium, sodium valproate, and topiramate have been evaluated in multiple Class I studies showing efficacy for prevention of migraine headaches. Long-term use of divalproex sodium has been associated with weight gain in multiple trials. As many as 15% of patients treated with topiramate in one study had adverse effects, including paresthesias, weight loss, and somnolence.

Beta-blockers including metoprolol, propranolol, timolol, atenolol, and nadolol also have been found effective for migraine headache prevention.

The antidepressant medications amitriptyline and venlafaxine have been found to be as efficacious as topiramate for prophylaxis, and should be considered for migraine prevention as well.

Frovatriptan used for short periods surrounding menstrual cycles to prevent menstrual-associated migraines has been shown to be effective.

A literature review has found evidence against the use of the following medications for prevention of migraine: lamotrigine, clomipramine, acebutolol, clonazepam, nabumetone, oxcarbazepine, montelukast, and telmisartan.

Evidence for the use of fluoxetine and calcium-channel blockers has previously been considered adequate; but this most recent review found insufficient data to make firm conclusions about benefits.

Lisinopril and candesartan were evaluated by a single study suggesting possible benefit in migraine prophylaxis; but at present, these remain Class C recommendations.

A second recent AAN guideline reviewed nonsteroidal anti-inflammatory drugs (NSAIDs) and a number of herbal preparations for migraine prevention, and found evidence of benefit for petasites (Butterbur extract) and less evidence for riboflavin, NSAIDs, magnesium, and other herbal therapies.

The AAN states that the lack of evidence to support a recommendation for a medication not listed above should not undervalue the clinician’s prior experience with a particular medication or class of medication when choosing a migraine prophylaxis regimen.

Implementation

Migraine headaches pose a significant burden to patients seen in the primary care setting, and many patients could benefit from attempted medical prophylaxis.

The medications listed above represent either Class A or Class B recommendations per the AAN 2012 guidelines, as well as those found to be ineffective.

The use of a particular medication or class of medications should be based on individual patient needs and comorbidities.

Women of childbearing age make up a large percentage of patients who may benefit from migraine prophylaxis. Medications with known teratogenicity, such as valproic acid, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers should be avoided in this group. The AAN specifically recommends against pharmacologic therapy for prophylaxis in patients for whom pregnancy is planned or anticipated.

Some evidence has been found for the use of NSAIDs for migraine prophylaxis; but this class of medications is not currently recommended, given the potential adverse effects with chronic NSAID use.

Studies show evidence for the use and benefit of a number of complementary products. But the lack of data regarding dosing strategies and interaction with pharmacologic agents, as well as the unregulated nature of these products, makes their use challenging in clinical practice.

The use of triptans for menstrual-associated migraines has not been approved by the FDA, because the question remains unanswered whether the benefit demonstrated in trials is clinically meaningful.

References

• Silberstein S.D., et al. Pharmacologic treatment for episodic migraine in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. (Neurology 2012;78;1337-45).

• Holland S., et al. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. (Neurology 2012;78;1346-53).

Dr. Vancil is an assistant professor of internal medicine at the University of Arkansas, Little Rock. Dr. Golden is medical director of Arkansas Medicaid and professor of medicine and public health at the University of Arkansas. Dr. Hopkins is director of the division of general internal medicine at the University of Arkansas. E-mail them at imnews@elsevier.com. They reported having no relevant financial conflicts. This column, "The Effective Physician," appears regularly in Internal Medicine News.

Background

Episodic migraine headache, defined as a migraine occurring less than 15 times a month, is a common malady affecting approximately 17% of women and 6% of men. The American Academy of Neurology published updated guidelines earlier this year to assist physicians in providing effective prophylaxis against episodic migraine headaches.

Conclusions

Prophylactic therapy is deemed necessary for patients with frequent headaches (more than four a month), long-lasting headaches (longer than 12 hours), or headaches causing a significant amount of physical disability.

The AAN estimates that 38% of people who suffer from migraine headaches meet criteria for preventative therapy, but only 3%-13% of these patients pursue or use it.

The goals of prophylactic treatment are to safely and effectively provide pharmacologic treatment to decrease headache frequency, reduce the number of migraine days, and reduce headache severity.

The antiepileptic drugs divalproex sodium, sodium valproate, and topiramate have been evaluated in multiple Class I studies showing efficacy for prevention of migraine headaches. Long-term use of divalproex sodium has been associated with weight gain in multiple trials. As many as 15% of patients treated with topiramate in one study had adverse effects, including paresthesias, weight loss, and somnolence.

Beta-blockers including metoprolol, propranolol, timolol, atenolol, and nadolol also have been found effective for migraine headache prevention.

The antidepressant medications amitriptyline and venlafaxine have been found to be as efficacious as topiramate for prophylaxis, and should be considered for migraine prevention as well.

Frovatriptan used for short periods surrounding menstrual cycles to prevent menstrual-associated migraines has been shown to be effective.

A literature review has found evidence against the use of the following medications for prevention of migraine: lamotrigine, clomipramine, acebutolol, clonazepam, nabumetone, oxcarbazepine, montelukast, and telmisartan.

Evidence for the use of fluoxetine and calcium-channel blockers has previously been considered adequate; but this most recent review found insufficient data to make firm conclusions about benefits.

Lisinopril and candesartan were evaluated by a single study suggesting possible benefit in migraine prophylaxis; but at present, these remain Class C recommendations.

A second recent AAN guideline reviewed nonsteroidal anti-inflammatory drugs (NSAIDs) and a number of herbal preparations for migraine prevention, and found evidence of benefit for petasites (Butterbur extract) and less evidence for riboflavin, NSAIDs, magnesium, and other herbal therapies.

The AAN states that the lack of evidence to support a recommendation for a medication not listed above should not undervalue the clinician’s prior experience with a particular medication or class of medication when choosing a migraine prophylaxis regimen.

Implementation

Migraine headaches pose a significant burden to patients seen in the primary care setting, and many patients could benefit from attempted medical prophylaxis.

The medications listed above represent either Class A or Class B recommendations per the AAN 2012 guidelines, as well as those found to be ineffective.

The use of a particular medication or class of medications should be based on individual patient needs and comorbidities.

Women of childbearing age make up a large percentage of patients who may benefit from migraine prophylaxis. Medications with known teratogenicity, such as valproic acid, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers should be avoided in this group. The AAN specifically recommends against pharmacologic therapy for prophylaxis in patients for whom pregnancy is planned or anticipated.

Some evidence has been found for the use of NSAIDs for migraine prophylaxis; but this class of medications is not currently recommended, given the potential adverse effects with chronic NSAID use.

Studies show evidence for the use and benefit of a number of complementary products. But the lack of data regarding dosing strategies and interaction with pharmacologic agents, as well as the unregulated nature of these products, makes their use challenging in clinical practice.

The use of triptans for menstrual-associated migraines has not been approved by the FDA, because the question remains unanswered whether the benefit demonstrated in trials is clinically meaningful.

References

• Silberstein S.D., et al. Pharmacologic treatment for episodic migraine in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. (Neurology 2012;78;1337-45).

• Holland S., et al. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. (Neurology 2012;78;1346-53).

Dr. Vancil is an assistant professor of internal medicine at the University of Arkansas, Little Rock. Dr. Golden is medical director of Arkansas Medicaid and professor of medicine and public health at the University of Arkansas. Dr. Hopkins is director of the division of general internal medicine at the University of Arkansas. E-mail them at imnews@elsevier.com. They reported having no relevant financial conflicts. This column, "The Effective Physician," appears regularly in Internal Medicine News.