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Neurology Now:
doi: 10.1097/01.NNN.0000415686.29779.a2
Departments: The Waiting Room

Neurology News: New migraine guidelines from the American Academy of Neurology

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If you are one of the roughly 30 million Americans who has migraines—recurrent headaches lasting from 4 to 72 hours and usually characterized by throbbing pain, nausea, vomiting, and extreme sensitivity to light or sound—you might benefit from preventive therapy, which involves taking a medication regularly instead of only when a headache strikes.

In fact, nearly 38 percent of people with migraines could benefit from preventive treatment, according to one study—but less than a third of patients take advantage of preventive treatment.

Now, two new guidelines from the American Academy of Neurology (AAN) and the American Headache Society provide an informed review of the evidence for a variety of pharmaceutical and complementary treatments for migraine prevention. Many experts suggest that if you have migraine attacks very frequently and find that acute medication (taken at the onset of pain) is not working or is causing side effects, preventive therapy may be appropriate.

Lead author Stephen D. Silberstein, M.D., professor of neurology and director of the Jefferson Headache Center at Thomas Jefferson University in Philadelphia, PA, and a Fellow of the AAN, says the pharmaceutical drugs shown to be effective by a high level of evidence (at least two consistent Class I studies) include the antiepileptic drugs topiramate (Topamax), sodium valproate (Epilim), and divalproex sodium (Depakote); and some beta blockers, including metoprolol (Lopressor, Toprol), propranolol (Inderal), and timolol (Istalol). For the short-term prevention of migraines associated with a woman's menstrual cycle, the use of frovatriptan (Frova) was shown to be effective.

A Class I study is a randomized, controlled clinical trial, which means people are chosen in adherence to rigorous criteria and then assigned at random to either a specific medical treatment or a placebo (sometimes known as a sugar pill). This type of study is also called placebo-controlled. (For more on levels of evidence and the classification of trials, see our articles: http://bit.ly/gTtAp6 and http://bit.ly/NNProof.)

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“These drugs have been shown through well-designed, placebo-controlled trials to prevent migraine,” Dr. Silberstein says. “As a doctor, it's always important to know as much as possible about the medications you are prescribing. Particularly, have they been shown to work?”

The absence of such evidence doesn't mean a drug won't work, Dr. Silberstein adds. “But it is and always has been good practice to know the evidence in order to make your own informed decisions,” he stresses.

The second guideline looks at complementary treatments and nonsteroidal anti-inflammatory drugs (NSAIDs) for migraine prevention. Butterbur, an herbal preparation, was shown to be effective by a high level of evidence, the authors wrote. Therapies that were shown probably to be effective (at least one Class I study or two Class II studies, which are considered less reliable than Class I studies) include the NSAIDs fenoprofen (Nalfon), ibuprofen (Advil, Motrin), ketoprofen (Orudis, Oruvail), naproxen (Aleve, Naprosyn), and naproxen sodium (Naprelan); the supplement magnesium; vitamin B2 (riboflavin); and the herbal preparation fevererfew (MIG-99). These treatments are often used in people who prefer not to use prescription pharmaceutical drugs or in combination with those drugs in order to enhance their benefit, Dr. Silberstein says.

However, complementary treatments—including vitamins, supplements, and herbal preparations—are drugs, stresses Gary Gronseth, M.D., professor and vice chairman of the neurology department at the University of Kansas in Kansas City, Fellow of the AAN, and member of the Neurology Now Editorial Advisory Board. “There is nothing intrinsically safe about them just because they don't require a prescription. Like all drugs, they have side effects and interact with other medications. Feverfew, for example, can interact with other drugs that are metabolized by the liver. Some of these interactions can be very serious.”

Migraine management still requires some trial and error on the part of doctor and patient—using available evidence from guidelines and knowledge of side effects, according to Dr. Silberstein. “There's no way of knowing in advance who is going to respond to which medication,” he says. For example, “topiramate is frequently associated with weight loss, so we might pick that as the drug of choice for someone who is overweight. We might prescribe tricyclic antidepressants, which have been associated with weight gain, in a patient who needs to gain weight,” he says.

Dr. Silberstein also cautions that not enough clinical evidence has been gathered to support the use of any one migraine treatment over another—that's an important research question that still needs to be addressed.

Most important, though, the guidelines show that many effective treatments are available for migraine, according to Dr. Silberstein. “Not all of them will work for everyone, but we do have options,” he says.

To access the full AAN guidelines for the prevention of migraine, visit www.aan.com/guidelines.

Go to neurologynow.com to watch a video interview with Dr. Gronseth about the new AAN migraine guidelines.

—Olga Rukovets

©2012 American Academy of Neurology

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