Preventive Therapy of Migraine

Todd J. Schwedt, MD, FAAN; Headache p. 1052-1065 August 2018, Vol.24, No.4 doi: 10.1212/CON.0000000000000635
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PURPOSE OF REVIEW: This article reviews the preventive therapy of migraine, including indications, strategies for use, and available treatments.

RECENT FINDINGS: Lifestyle modifications and migraine trigger avoidance are recommended as preventive measures for all individuals with migraine. The decision to recommend additional migraine preventive therapy should consider the frequency of migraine attacks and headaches, extent of migraine-associated disability, frequency of using acute migraine treatments and the responsiveness to such treatments, and patient preferences. Additional therapies include prescription medications, nutraceuticals, neurostimulation, and behavioral therapy. Considering evidence for efficacy and the risk of potential side effects and adverse events, treatments with the most favorable profiles include (in alphabetical order): amitriptyline, beta-blockers (several), biofeedback, candesartan, coenzyme Q10, cognitive-behavioral therapy, magnesium citrate, onabotulinumtoxinA (for chronic migraine only), relaxation therapy, riboflavin, and topiramate. In addition, erenumab, a calcitonin gene-related peptide (CGRP) receptor monoclonal antibody, received approval from the US Food and Drug Administration (FDA) for the prevention of migraine in May 2018.

SUMMARY: Successful migraine preventive therapy reduces the frequency and burden of attacks while causing limited side effects. Individual treatment recommendations are determined based upon evidence for efficacy, side effect and adverse event profiles, medication interactions, patient comorbidity, costs, and patient preferences. Patients must be counseled on reasonable expectations for their preventive therapy and the importance of adhering to the recommended treatment plan for a period of time that is sufficient to determine outcomes.

Address correspondence to Dr Todd J. Schwedt, Mayo Clinic, 5777 East Mayo Blvd, Phoenix, AZ 85054, Schwedt.todd@mayo.edu.

RELATIONSHIP DISCLOSURE: Dr Schwedt serves on the board of directors for the American Headache Society and the International Headache Society; receives personal compensation as associate editor for Cephalalgia, Headache, and Pain Medicine; and receives personal compensation as a consultant for Alder BioPharmaceuticals, Inc; Allergan; Amgen Inc; Autonomic Technologies, Inc; Avanir Pharmaceuticals, Inc; Dr. Reddy’s Laboratories Ltd; Eli Lilly and Company; Ipsen Bioscience, Inc; Nocira, LLC; Novartis AG; and Teva Pharmaceutical Industries Ltd. He has stock options in Aural Analytics; Nocira, LLC; and Second Opinion. Dr Schwedt has received research/grant support from the American Migraine Foundation, the National Institutes of Health, Patient-Centered Outcomes Research Institute, and the United States Department of Defense. Dr Schwedt has received publishing royalties from UpToDate, Inc.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Schwedt discusses the unlabeled/investigational use of numerous medications for the treatment of migraine; none of the therapies discussed are approved by the US Food and Drug Administration except for caloric vestibular stimulation, divalproex sodium, erenumab, propranolol, timolol, topiramate, transcranial magnetic stimulation, and transcutaneous supraorbital nerve stimulation for the treatment of migraine and the use of onabotulinumtoxinA for the treatment of chronic migraine.

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© 2018 American Academy of Neurology