New migraine prevention recommendations from the AAN

This week, neurologists and headache specialists from across the country have convened in New Orleans for the annual meeting of the American Academy of Neurology to hear the latest breakthroughs and recommendations for treating neurological conditions, like migraine.

At this year's meeting, attendees will be among the first to hear about new migraine recommendations that were just published in the journal Neurology.1 These guidelines target prevention drug therapy for patients with episodic migraine. Episodic migraine is defined as migraine typically occurring less than 15 days per month. When migraine occurs more frequently, it's called chronic migraine. This distinction is relatively new and fewer studies have tested migraine prevention therapies in patients with chronic migraine. The current guidelines, therefore, focus on treatment of patients with frequent episodic migraines. The guidelines do not address non-drug treatments that might effectively reduce migraine frequency or severity, like relaxation, biofeedback, stress management, exercise, etc. The guidelines also don't address botox as a prevention therapy, with a notation that botox will be addressed in a subsequently published report.

In general, migraine prevention is considered when people regularly experience more than a couple migraines each week or migraines don't respond to acute management. It's estimated that about two of five people with migraine would benefit from prevention therapy. Unfortunately, only about half of those who are candidates are prescribed preventive treatments. Migraine prevention can include both drug and non-drug treatments and studies show that people tend to get the best relief when including non-drug treatments along with their medication therapies.

New recommendations developed by the American Academy of Neurology and American Headache Society (Pharmacologic Treatment For Episodic Migraine Prevention in Adults) include traditional medication and complementary drug treatments. Here's a summary of important new recommendations just published in Neurology:

Migraine prevention drugs

These recommendations address prescription drugs that are traditionally used for migraine prevention.

  • Drugs that have the strongest evidence supporting their effectiveness as migraine prevention include: antiepileptic drugs (valproate and topiramate) and beta-blockers (metoprolol, propranolol, timolol). There's also strong evidence supporting frovatriptan as short-term prevention for menstrual migraines.
  • Drugs that are probably effective preventives, although the evidence is not as strong, include: antidepressants (amitriptyline and venlafaxine) and some other beta-blockers (atenolol and nadolol). Naratriptan and zolmitriptan may be effective preventives for menstrual migraine.
  • Other drugs commonly used for migraine prevention, like calcium channel blockers and other antihypertensives, newer antidepressants (like selective serotonin reuptake inhibitors and selective serotonin-norepinephrine reuptake inhibitors) and gabapentin don't have strong evidence supporting their benefit as migraine prevention therapies.
  • The antiepilepsy drug lamotrigine and the antidepressant clomipramine have been shown to be ineffective for migraine prevention.

Patient tools describing recommendations, including a podcast, can be accessed online at the American Academy of Neurology website.

The new recommendations reinforce that, unfortunately, finding the best drug for the individual patient often requires trying several drugs before the best match is found. It's also important to consider your other health conditions and which side effects are most likely to be bothersome to you when selecting specific treatments for you.

Nonsteroidal anti-inflammatory (ibuprofen-like) drugs and complementary treatments for migraine prevention2

These recommendations address the use of over-the-counter and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) and herbal or nutritional therapies for migraine prevention.

  • Petasites (or butterbur) has strong evidence that it is an effective migraine prevention therapy.
  • Therapies that are also probably effective migraine preventives include: riboflavin, magnesium, feverfew, some NSAIDs (fenoprofen, ibuprofen, ketoprofen, and naproxen), and subcutaneous histamine injections.
  • Strong evidence is lacking to support migraine prevention benefits from coenzyme Q10 and omega-3.
  • The asthma medication montelukast is ineffective as a migraine prevention therapy.

Although NSAIDs can effectively prevent migraine, long-term daily use can result in medication overuse headache, especially with ibuprofen. In addition, long-term regular use of NSAIDs is generally discouraged due to concerns about side effects, such as stomach and kidney toxicity.

What about chronic migraine?

The current guidelines do not directly address chronic migraine treatment. A recent report from the Mayo Clinic published in the journal Seminars in Neurology provided a summary of studies where drug prevention was specifically targeted in people with chronic migraine. Drugs that were shown to be effective for chronic migraine in controlled, randomized research studies included:

  • Antiepileptic drugs topiramate and gabapentin
  • Antidepressants amitriptyline and fluoxetine
  • Muscle relaxant tizanidine

Botox is also approved for the prevention treatment of chronic migraine. The National Institutes of Health is currently conducting a study to test the benefits of a low omega-3 (avoid most oils; add vegetarian meals, lean fish, egg whites)/high omega-6 diet (add flaxseed and fatty fish [canned tuna, salmon, trout] for reducing chronic daily headache, with results expected in 2013

References 1. Silberstein SD, Holland S,Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults. Neurology 2012;78:1337-1345.2.Holland S, Silberstein SD, Freitag F, Dodick DW, Argoff C, Ashman E. 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—1353

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This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

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