Migraine Headache Prophylaxis

 

Migraines impose significant health and financial burdens. Approximately 38% of patients with episodic migraines would benefit from preventive therapy, but less than 13% take prophylactic medications. Preventive medication therapy reduces migraine frequency, severity, and headache-related distress. Preventive therapy may also improve quality of life and prevent the progression to chronic migraines. Some indications for preventive therapy include four or more headaches a month, eight or more headache days a month, debilitating headaches, and medication-overuse headaches. Identifying and managing environmental, dietary, and behavioral triggers are useful strategies for preventing migraines. First-line medications established as effective based on clinical evidence include divalproex, topiramate, metoprolol, propranolol, and timolol. Medications such as amitriptyline, venlafaxine, atenolol, and nadolol are probably effective but should be second-line therapy. There is limited evidence for nebivolol, bisoprolol, pindolol, carbamazepine, gabapentin, fluoxetine, nicardipine, verapamil, nimodipine, nifedipine, lisinopril, and candesartan. Acebutolol, oxcarbazepine, lamotrigine, and telmisartan are ineffective. Newer agents target calcitonin gene-related peptide pain transmission in the migraine pain pathway and have recently received approval from the U.S. Food and Drug Administration; however, more studies of long-term effectiveness and adverse effects are needed. The complementary treatments petasites, feverfew, magnesium, and riboflavin are probably effective. Nonpharmacologic therapies such as relaxation training, thermal biofeedback combined with relaxation training, electromyographic feedback, and cognitive behavior therapy also have good evidence to support their use in migraine prevention.

The disabling nature of migraine headaches causes frequent visits to outpatient clinic and emergency department settings, imposing significant health and financial burdens. Headaches rank among the top five reasons for emergency department visits and top 20 reasons for outpatient visits.1 The prevalence of migraines is an estimated 16%; they are more common in women, with a peak sex prevalence ratio of 3:1.1 Approximately 38% of persons who have episodic migraines would benefit from prophylactic therapy, but only 3% to 13% obtain it.2

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SORT: KEY CLINICAL RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Preventive therapy should be considered in patients having four or more headaches a month or at least eight headache days a month, significantly debilitating attacks despite appropriate acute management, difficulty tolerating or having a contraindication to acute therapy, medication overuse headache, patient preference, or the presence of certain migraine subtypes (i.e., hemiplegic migraine; migraine with brainstem aura; migrainous infarction; or frequent, persistent, or uncomfortable aura symptoms).

C

8

Divalproex (Depakote), topiramate (Topamax), metoprolol, propranolol, and timolol are effective for migraine prevention and should be offered as first-line treatment.

A

79, 1118

Petasites has been established as effective and can be considered for migraine prevention.

B

29, 30

Behavioral treatments, such as relaxation training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive behavior therapy, are effective options for migraine prevention.

B

11, 32

Adding acupuncture to symptomatic treatment decreases the frequency of migraine headaches.

A

33


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY CLINICAL RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Preventive therapy should be considered in patients having four or more headaches a month or at least eight headache days a month, significantly debilitating attacks despite appropriate acute management, difficulty tolerating or having a contraindication to acute therapy, medication overuse headache, patient preference, or the presence of certain migraine subtypes (i.e., hemiplegic migraine; migraine with brainstem aura; migrainous infarction; or frequent, persistent, or uncomfortable aura symptoms).

C

8

Divalproex (Depakote), topiramate (Topamax), metoprolol, propranolol, and timolol are effective for migraine prevention and should be offered as first-line treatment.

A

79, 1118

Petasites has been established as effective and can be considered for migraine prevention.

B

29, 30

Behavioral treatments, such as relaxation training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive behavior

The Authors

show all author info

HIEN HA, PharmD, is an associate professor at the University of the Incarnate Word, Feik School of Pharmacy, and a clinical pharmacist specialist and faculty at Christus Santa Rosa Family Medicine Residency Program, San Antonio, Tex....

ANNIKA GONZALEZ, MD, is a faculty physician at Christus Santa Rosa Family Medicine Residency Program and section chief of pediatrics at Santa Rosa Westover Hills Hospital, San Antonio.

Address correspondence to Hien Ha, PharmD, University of the Incarnate Word, 4301 Broadway #99, San Antonio, TX 78209 (e-mail: hha@uiwtx.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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