Migraine Guidelines Evaluate Efficacy of Treatments

New Orleans—Despite many treatments available to help prevent migraine in certain people, most migraine sufferers do not use them, according to Stephen D. Silberstein, MD, FACP, FAHS, coauthor of 2 practice guidelines on prevention of episodic migraine [Neurology. 2012;78(17):1337-1353]. The guidelines—one for prescription medications and another for nonsteroidal anti-inflammatory drugs (NSAIDs) and complementary treatments—were codeveloped by the American Academy of Neurology (AAN) and the American Headache Society.

“Studies show that migraine is under-recognized and undertreated,” said Dr. Silberstein at the recent AAN meeting, where the new guidelines were announced. “About 38% of people who suffer from migraine could benefit from preventive treatments, but only less than a third of these people currently use them. Some studies show that migraine attacks can be reduced by more than half with prevention treatments.”

Unlike acute treatments, which are used to relieve the pain and associated symptoms of a migraine attack when it happens, preventive treatments are usually taken daily to prevent frequency of attacks and to lessen the severity and duration when the episodes do occur.

To provide updated evidence-based recommendations for the preventive treatment of migraine headache, the authors analyzed published studies from June 1999 to May 2009 using a structured review process to classify the evidence relative to the efficacy of various medications available in the United States for migraine prevention. The guidelines for prescription drugs are based on research evidence from 29 prevention studies, and the guidelines for NSAIDs and complementary therapies are based on 15 prevention studies.

Prescription drugs listed as having proven effectiveness against migraine include a triptan agent, 3 beta-blockers, and 3 antiepileptic drugs. Specific prescription drugs with a Level A recommendation, indicating proven efficacy in ≥2 Class I trials, are listed in Table 1.

Drugs with a Level B recommendation and classified as “probably effective” based on 1 Class I or 2 Class II studies include the antidepressants amitriptyline and venlafaxine, beta-blockers atenolol and nadolol, and triptans naratriptan and zolmitriptan for prevention of menstrual migraine.

The review found the seizure drug lamotrigine ineffective for migraine prevention. The review stated that the 2000 guideline reported a single Class I lamotrigine study that did not show a significant effect for migraine prevention. A second, new Class I study comparing lamotrigine 50 mg/day with placebo or topiramate 50 mg/day found that lamotrigine was not more effective than placebo and was less effective than topiramate in reducing migraine frequency and intensity.

The guidelines did not address the use of botulinum toxin-based drugs for migraine because these were covered in a separate AAN review published in 2008. The guideline included a Level B recommendation that botulinum toxin was “probably effective” for the treatment of episodic migraine. A new guideline is in development, according to AAN.

As for over-the counter (OTC) products, Level A recommendations (proven efficacy in ≥2 Class I trials) included herbal preparations, vitamins, and minerals, and other interventions. Butterbur, also a Level A recommendation, was effective for migraine prevention and should be a therapy offered by clinicians for patients with migraine to reduce the frequency and severity of migraine attacks. Other treatments classified as “probably effective” and given Level B recommendations include NSAIDs, complementary treatments, and histamines (see Table 2).

Treatments recommended as Level C based on a Class II study and deemed “probably effective” are cypropheptadine, Co-Q10, estrogen, mefenamic acid, and flurbiprofen. Data are conflicting or inadequate to support or refute the use of aspirin, indomethacin, omega-3, or hyperbaric oxygen for migraine prevention. The review classified monteulukast as “probably ineffective” for migraine prevention.

Dr. Silberstein noted that while many people do not need a prescription from a physician for these OTC and complementary treatments, they should still see their physician for regular follow-up. “Migraines can get better or worse over time, and people should discuss these changes in the pattern of attacks with their doctors and see whether they need to adjust their dose or even stop their medication and/or switch to a different medication,” he said. “In addition, people need to keep in mind that all drugs, including over-the-counter drugs and complementary treatments, can have side effects or interact with other medications and should be monitored.”