Transforming Healthcare with Evidence

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Dr. Tony Melaragno
Chief Administrative Officer and Clinical VP of Research, Legacy Good Samaritan Hospital

New Guidelines for Preventing Migraine

Wednesday, April 25th, 2012

Preventive treatment of migraine is the focus of updated guidelines 1,2 co-published by the American Academy of Neurology (AAN) and the American Headache Society. According to data presented at the 64th Annual Meeting of the AAN, few people with migraine use preventive treatment—although many different preventive strategies are available. The AAN last updated its prevention guidelines in 2000.

According to data cited in the guidelines, migraine is both underrecognized and undertreated. According to data cited in the published guidelines, 38% of people who suffer from migraine could benefit from preventive treatments, and less than a third use preventive treatments.

Unlike acute treatments, which are used to relieve the pain and associated symptoms of a migraine attack when it occurs, preventive treatments are typically taken every day to prevent attacks from occurring and to lessen their severity and duration when they do occur. Some studies show that migraine attacks can be reduced by more than half with preventive treatments.

The guidelines reviewed all of the available evidence on migraine prevention for prescription, over-the-counter, and complementary treatments. The review did not address the magnitude of any given agent’s efficacy—only the strength of evidence backing their superiority relative to placebo. The guidelines do not include any evidence related to lifestyle changes.

Among the prescription drugs, three seizure drugs (divalproex sodium, sodium valproate, and topiramate) and three beta-blockers (metoprolol, propranolol, and timolol) were effective for migraine prevention and should be offered to people with migraine to reduce the frequency and severity of attacks. Frovatriptan, a statin, was found to be effective in the prevention of menstrual migraines. Of note is that the seizure drug lamotrigine was found to be ineffective in preventing migraine.

The guidelines also reviewed over-the-counter treatments and complementary treatments. The guideline found that the herbal preparation Petasites (butterbur) appears to be effective in preventing migraine. Other treatments found to be “probably effective” are the nonsteroidal anti-inflammatory drugs fenoprofen, ibuprofen, ketoprofen, naproxen and naproxen sodium, subcutaneous histamine and complementary treatments magnesium, MIG-99 (feverfew), and riboflavin.

The guidelines note that while people do not need a prescription from a physician for over-the-counter and complementary treatments, they still should see a healthcare provider regularly for follow-up. Because migraines can get better or worse over time, 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 or switch to a different medication. 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, which should be monitored.

According to the AAN, migraines led to more than 3 million emergency room visits in the United States in 2008, the last date for which data are available.

  1. Silberstein S, 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(17):1337-1345. Abstract available at: http://www.neurology.org/content/78/17/1337.full. Accessed April 25, 2012.
  2. Holland S, Silberstein F, Freitag F, Dodick DW, Argoff C, Ashman E . Evidence-bsaed guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults. Neurology. 2012;78(17):1346-1353. Abstract available at: http://www.neurology.org/content/78/17/1346.full. Accessed April 25, 2012.

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