What Is the Best Migraine Prevention Therapy?

STOWE, VERMONT—Many treament options are available for migraine prevention. Developing customized treatment strategies for patients is essential. At the 26th Annual Stowe Headache Symposium of the Headache Cooperative of New England, Peter McAllister, MD, discussed the most efficacious migraine prevention therapies. He also gave guidance on deciding who needs preventive therapy and how to choose the right preventive treatment for each patient.

Who Needs Migraine Prevention Therapy?

Migraine prevention therapy is underutilized. Thirty-eight percent of patients could benefit from migraine prevention therapy, but only 3% to 13% are actually receiving it, according to 2012 guidelines from the AAN and the American Headache Society. Frequency of headaches and functional disability are the main criteria for deciding which patients need preventive treatment. According to the 2012 US Headache Consortium Guidelines, migraineurs with six or more headache days per month, four or more headache days with functional disability, or three or more headache days per month resulting in disability requiring bed rest, should be offered migraine preventive medication. The Canadian Prophylactic Guidelines Development Group 2012 recommended that prophylactic therapy be considered for patients whose migraine attacks have a significant impact on their lives, despite appropriate use of acute medications, trigger management, and lifestyle modification strategies.

Disability may be the more important of the two criteria. “If [a patient is] disabled, we really have to push and be aggressive with preventive medications,” said Dr. McAllister, Medical Director of the New England Institute for Neurology and Headache in Stamford, Connecticut. A guiding principle to consider when deciding who should receive preventive therapy is that an accurate diagnosis follows the International Headache Society, third edition (ICHD-3) guidelines. Dr. McAllister also advised doctors to make sure that patients keep headache diaries and to set realistic treatment goals. He also emphasized the importance of understanding patients’ medical and psychiatric conditions. In general, drug treatment should start with a low dose and slowly be titrated to a therapeutic dose. In addition, preventive treatment should be included as part of an overall plan that encompasses lifestyle changes, trigger reduction, and a strategy for withdrawal of medication.

Pharmacologic Options

The FDA has approved several drugs for migraine prevention, including divalproex sodium, topiramate, propranolol, timolol, and methysergide. Of all classes of migraine preventive therapy, antiseizure medications have the most support in the data. Topiramate is “a top choice” for migraine prevention because Class I evidence supports its efficacy and it is fairly well tolerated, said Dr. McAllister. Topiramate was also approved for children based on a double-blind study of participants between ages 12 and 17. Divalproex, another antiseizure medication, has high efficacy, but side effects such as weight gain, hair loss, tremor, teratogenicity, increased liver function tests, and increased risk for pancreatitis make the drug unattractive to many.

Antihypertensive medicines also may be used for migraine prevention. Much research supports the efficacy of beta blockers in migraine prevention, and doctors can help patients manage their associated side effects. Metoprolol, a beta blocker, may be more tolerable for someone with asthma or glucose issues because it is selective for β1. Although physicians have used verapamil, a calcium channel blocker, for migraine prevention, the most recent guidelines give a Level U recommendation for its use because of conflicting or insufficient evidence. Lisinopril, an angiotensin-converting-enzyme inhibitor, and candesartan, an angiotensin receptor blocking agent, have good side effect profiles. These drugs are recommended for patients with mild hypertension. American guidelines provide a Level C recommendation of clonidine, but Canadian guidelines recommend against using the drug because of insufficient evidence and concern about the side effects.

Nonpharmacologic Options

Neurologists who seek to avoid pharmacologic treatments may choose options such as biologics or neurostimulators. OnabotulinumtoxinA injections are approved for patients with chronic migraine. Administered properly, the treatment has no systemic side effects and few local side effects.

In 2014, the FDA allowed the Cefaly device, which stimulates the trigeminal nerve, to be marketed for the prevention of migraine. In 2013, 67 patients with migraine were randomized to supraorbital stimulation with Cefaly or sham stimulation. The number of headache days per month decreased from seven to five among the participants randomized to Cefaly. Patients who received sham stimulation had no change in this end point.

Some patients may be interested in complementary or alternative treatment options like biofeedback. Biofeedback allows patients to monitor and change certain physiologic parameters (eg, muscle contraction and skin temperature) and is used to treat insomnia and anxiety. This therapy can be combined with a migraine preventive drug for the best results. Controlled studies indicate that biofeedback can result in a 45% to 60% headache reduction. When combined with medication, biofeedback reduces headache by more than 70%. Children and adolescents can also benefit from this treatment.

Selecting Individualized Migraine Prevention Treatment

Once a neurologist has given a proper diagnosis, he or she should thoroughly review the patient’s profile to select the proper migraine prevention therapy. Gender, age, childbearing potential, and BMI are factors to consider when finding the best treatment for a given patient. “When you know you have to put someone on a medicine, you should know the side effects and be able to discuss them,” said Dr. McAllister. “I like to come up with a scatter plot in my head looking at increasing safety and tolerability on the y axis and increasing efficacy on the x axis…. If someone is really sensitive, you might want to aim towards the more tolerable medications.” For a patient with exceptionally painful headaches, it’s better to treat with highly efficacious drugs, despite their side effects, he added.

No migraine preventive therapy is pregnancy category A, said Dr. McAllister. None has been demonstrated safe for the unborn child. Nonsteroidal anti-inflammatory drugs are pregnancy category B and are recommended only during the first two trimesters. Metoclopramide and acetaminophen are also pregnancy category B. Category C drugs include amitriptyline, propranolol, verapamil, and onabotulinumtoxinA injections. Topiramate should not be used during pregnancy because it increases the risk for cleft palate in the child. Clear evidence indicates that divalproex is a teratogen.

Every patient with migraine should work with his or her doctor to find the most efficacious strategy for treatment. “What is the ideal migraine preventive drug? It should decrease the number of headache days or attacks, attenuate the intensity—of not just the pain, but the associated symptoms—render acute treatment, be effective, and have low or no side effects,” Dr. McAllister concluded.

—Erica Robinson

STOWE, VERMONT—Many treament options are available for migraine prevention. Developing customized treatment strategies for patients is essential. At the 26th Annual Stowe Headache Symposium of the Headache Cooperative of New England, Peter McAllister, MD, discussed the most efficacious migraine prevention therapies. He also gave guidance on deciding who needs preventive therapy and how to choose the right preventive treatment for each patient.

Who Needs Migraine Prevention Therapy?

Migraine prevention therapy is underutilized. Thirty-eight percent of patients could benefit from migraine prevention therapy, but only 3% to 13% are actually receiving it, according to 2012 guidelines from the AAN and the American Headache Society. Frequency of headaches and functional disability are the main criteria for deciding which patients need preventive treatment. According to the 2012 US Headache Consortium Guidelines, migraineurs with six or more headache days per month, four or more headache days with functional disability, or three or more headache days per month resulting in disability requiring bed rest, should be offered migraine preventive medication. The Canadian Prophylactic Guidelines Development Group 2012 recommended that prophylactic therapy be considered for patients whose migraine attacks have a significant impact on their lives, despite appropriate use of acute medications, trigger management, and lifestyle modification strategies.

Disability may be the more important of the two criteria. “If [a patient is] disabled, we really have to push and be aggressive with preventive medications,” said Dr. McAllister, Medical Director of the New England Institute for Neurology and Headache in Stamford, Connecticut. A guiding principle to consider when deciding who should receive preventive therapy is that an accurate diagnosis follows the International Headache Society, third edition (ICHD-3) guidelines. Dr. McAllister also advised doctors to make sure that patients keep headache diaries and to set realistic treatment goals. He also emphasized the importance of understanding patients’ medical and psychiatric conditions. In general, drug treatment should start with a low dose and slowly be titrated to a therapeutic dose. In addition, preventive treatment should be included as part of an overall plan that encompasses lifestyle changes, trigger reduction, and a strategy for withdrawal of medication.

Pharmacologic Options

The FDA has approved several drugs for migraine prevention, including divalproex sodium, topiramate, propranolol, timolol, and methysergide. Of all classes of migraine preventive therapy, antiseizure medications have the most support in the data. Topiramate is “a top choice” for migraine prevention because Class I evidence supports its efficacy and it is fairly well tolerated, said Dr. McAllister. Topiramate was also approved for children based on a double-blind study of participants between ages 12 and 17. Divalproex, another antiseizure medication, has high efficacy, but side effects such as weight gain, hair loss, tremor, teratogenicity, increased liver function tests, and increased risk for pancreatitis make the drug unattractive to many.

Antihypertensive medicines also may be used for migraine prevention. Much research supports the efficacy of beta blockers in migraine prevention, and doctors can help patients manage their associated side effects. Metoprolol, a beta blocker, may be more tolerable for someone with asthma or glucose issues because it is selective for β1. Although physicians have used verapamil, a calcium channel blocker, for migraine prevention, the most recent guidelines give a Level U recommendation for its use because of conflicting or insufficient evidence. Lisinopril, an angiotensin-converting-enzyme inhibitor, and candesartan, an angiotensin receptor blocking agent, have good side effect profiles. These drugs are recommended for patients with mild hypertension. American guidelines provide a Level C recommendation of clonidine, but Canadian guidelines recommend against using the drug because of insufficient evidence and concern about the side effects.

Nonpharmacologic Options

Neurologists who seek to avoid pharmacologic treatments may choose options such as biologics or neurostimulators. OnabotulinumtoxinA injections are approved for patients with chronic migraine. Administered properly, the treatment has no systemic side effects and few local side effects.

In 2014, the FDA allowed the Cefaly device, which stimulates the trigeminal nerve, to be marketed for the prevention of migraine. In 2013, 67 patients with migraine were randomized to supraorbital stimulation with Cefaly or sham stimulation. The number of headache days per month decreased from seven to five among the participants randomized to Cefaly. Patients who received sham stimulation had no change in this end point.

Some patients may be interested in complementary or alternative treatment options like biofeedback. Biofeedback allows patients to monitor and change certain physiologic parameters (eg, muscle contraction and skin temperature) and is used to treat insomnia and anxiety. This therapy can be combined with a migraine preventive drug for the best results. Controlled studies indicate that biofeedback can result in a 45% to 60% headache reduction. When combined with medication, biofeedback reduces headache by more than 70%. Children and adolescents can also benefit from this treatment.

Selecting Individualized Migraine Prevention Treatment

Once a neurologist has given a proper diagnosis, he or she should thoroughly review the patient’s profile to select the proper migraine prevention therapy. Gender, age, childbearing potential, and BMI are factors to consider when finding the best treatment for a given patient. “When you know you have to put someone on a medicine, you should know the side effects and be able to discuss them,” said Dr. McAllister. “I like to come up with a scatter plot in my head looking at increasing safety and tolerability on the y axis and increasing efficacy on the x axis…. If someone is really sensitive, you might want to aim towards the more tolerable medications.” For a patient with exceptionally painful headaches, it’s better to treat with highly efficacious drugs, despite their side effects, he added.

No migraine preventive therapy is pregnancy category A, said Dr. McAllister. None has been demonstrated safe for the unborn child. Nonsteroidal anti-inflammatory drugs are pregnancy category B and are recommended only during the first two trimesters. Metoclopramide and acetaminophen are also pregnancy category B. Category C drugs include amitriptyline, propranolol, verapamil, and onabotulinumtoxinA injections. Topiramate should not be used during pregnancy because it increases the risk for cleft palate in the child. Clear evidence indicates that divalproex is a teratogen.

Every patient with migraine should work with his or her doctor to find the most efficacious strategy for treatment. “What is the ideal migraine preventive drug? It should decrease the number of headache days or attacks, attenuate the intensity—of not just the pain, but the associated symptoms—render acute treatment, be effective, and have low or no side effects,” Dr. McAllister concluded.

—Erica Robinson

STOWE, VERMONT—Many treament options are available for migraine prevention. Developing customized treatment strategies for patients is essential. At the 26th Annual Stowe Headache Symposium of the Headache Cooperative of New England, Peter McAllister, MD, discussed the most efficacious migraine prevention therapies. He also gave guidance on deciding who needs preventive therapy and how to choose the right preventive treatment for each patient.

Who Needs Migraine Prevention Therapy?

Migraine prevention therapy is underutilized. Thirty-eight percent of patients could benefit from migraine prevention therapy, but only 3% to 13% are actually receiving it, according to 2012 guidelines from the AAN and the American Headache Society. Frequency of headaches and functional disability are the main criteria for deciding which patients need preventive treatment. According to the 2012 US Headache Consortium Guidelines, migraineurs with six or more headache days per month, four or more headache days with functional disability, or three or more headache days per month resulting in disability requiring bed rest, should be offered migraine preventive medication. The Canadian Prophylactic Guidelines Development Group 2012 recommended that prophylactic therapy be considered for patients whose migraine attacks have a significant impact on their lives, despite appropriate use of acute medications, trigger management, and lifestyle modification strategies.

Disability may be the more important of the two criteria. “If [a patient is] disabled, we really have to push and be aggressive with preventive medications,” said Dr. McAllister, Medical Director of the New England Institute for Neurology and Headache in Stamford, Connecticut. A guiding principle to consider when deciding who should receive preventive therapy is that an accurate diagnosis follows the International Headache Society, third edition (ICHD-3) guidelines. Dr. McAllister also advised doctors to make sure that patients keep headache diaries and to set realistic treatment goals. He also emphasized the importance of understanding patients’ medical and psychiatric conditions. In general, drug treatment should start with a low dose and slowly be titrated to a therapeutic dose. In addition, preventive treatment should be included as part of an overall plan that encompasses lifestyle changes, trigger reduction, and a strategy for withdrawal of medication.

Pharmacologic Options

The FDA has approved several drugs for migraine prevention, including divalproex sodium, topiramate, propranolol, timolol, and methysergide. Of all classes of migraine preventive therapy, antiseizure medications have the most support in the data. Topiramate is “a top choice” for migraine prevention because Class I evidence supports its efficacy and it is fairly well tolerated, said Dr. McAllister. Topiramate was also approved for children based on a double-blind study of participants between ages 12 and 17. Divalproex, another antiseizure medication, has high efficacy, but side effects such as weight gain, hair loss, tremor, teratogenicity, increased liver function tests, and increased risk for pancreatitis make the drug unattractive to many.

Antihypertensive medicines also may be used for migraine prevention. Much research supports the efficacy of beta blockers in migraine prevention, and doctors can help patients manage their associated side effects. Metoprolol, a beta blocker, may be more tolerable for someone with asthma or glucose issues because it is selective for β1. Although physicians have used verapamil, a calcium channel blocker, for migraine prevention, the most recent guidelines give a Level U recommendation for its use because of conflicting or insufficient evidence. Lisinopril, an angiotensin-converting-enzyme inhibitor, and candesartan, an angiotensin receptor blocking agent, have good side effect profiles. These drugs are recommended for patients with mild hypertension. American guidelines provide a Level C recommendation of clonidine, but Canadian guidelines recommend against using the drug because of insufficient evidence and concern about the side effects.

Nonpharmacologic Options

Neurologists who seek to avoid pharmacologic treatments may choose options such as biologics or neurostimulators. OnabotulinumtoxinA injections are approved for patients with chronic migraine. Administered properly, the treatment has no systemic side effects and few local side effects.

In 2014, the FDA allowed the Cefaly device, which stimulates the trigeminal nerve, to be marketed for the prevention of migraine. In 2013, 67 patients with migraine were randomized to supraorbital stimulation with Cefaly or sham stimulation. The number of headache days per month decreased from seven to five among the participants randomized to Cefaly. Patients who received sham stimulation had no change in this end point.

Some patients may be interested in complementary or alternative treatment options like biofeedback. Biofeedback allows patients to monitor and change certain physiologic parameters (eg, muscle contraction and skin temperature) and is used to treat insomnia and anxiety. This therapy can be combined with a migraine preventive drug for the best results. Controlled studies indicate that biofeedback can result in a 45% to 60% headache reduction. When combined with medication, biofeedback reduces headache by more than 70%. Children and adolescents can also benefit from this treatment.

Selecting Individualized Migraine Prevention Treatment

Once a neurologist has given a proper diagnosis, he or she should thoroughly review the patient’s profile to select the proper migraine prevention therapy. Gender, age, childbearing potential, and BMI are factors to consider when finding the best treatment for a given patient. “When you know you have to put someone on a medicine, you should know the side effects and be able to discuss them,” said Dr. McAllister. “I like to come up with a scatter plot in my head looking at increasing safety and tolerability on the y axis and increasing efficacy on the x axis…. If someone is really sensitive, you might want to aim towards the more tolerable medications.” For a patient with exceptionally painful headaches, it’s better to treat with highly efficacious drugs, despite their side effects, he added.

No migraine preventive therapy is pregnancy category A, said Dr. McAllister. None has been demonstrated safe for the unborn child. Nonsteroidal anti-inflammatory drugs are pregnancy category B and are recommended only during the first two trimesters. Metoclopramide and acetaminophen are also pregnancy category B. Category C drugs include amitriptyline, propranolol, verapamil, and onabotulinumtoxinA injections. Topiramate should not be used during pregnancy because it increases the risk for cleft palate in the child. Clear evidence indicates that divalproex is a teratogen.

Every patient with migraine should work with his or her doctor to find the most efficacious strategy for treatment. “What is the ideal migraine preventive drug? It should decrease the number of headache days or attacks, attenuate the intensity—of not just the pain, but the associated symptoms—render acute treatment, be effective, and have low or no side effects,” Dr. McAllister concluded.

—Erica Robinson