New Guidelines for Preventing MigrainePrint This Post
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 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).
Migraine is a common type of headache that typically occurs with symptoms such as nausea, vomiting, or sensitivity to light. The classic migraine episode is characterized by unilateral head pain preceded by various visual, sensory, or motor symptoms, collectively known as an aura. A migraine is caused by abnormal brain activity, which can be triggered by a number of factors; however, the exact chain of events remains unclear. Today, most neurologists believe the attack begins in the brain and involves nerve pathways and chemicals. The changes affect blood flow in the brain and surrounding tissues.
In the current International Headache Society (IHS) categorization, the headache previously described as classic migraine is now known as migraine with aura, and that described as common migraine is now termed migraine without aura. Migraines without aura are the most common, accounting for more than 80% of all migraines. Migraine headaches tend to first appear between the ages of 10 and 45, although they may begin later in life. In addition,
- Migraines occur much more often in women than men
- Some women, but not all, may have fewer migraines when they are pregnant
- The incidence and disability of migraine may decrease once women are postmenopausal
- Family history seems to be a strong risk factor for migraine. There is a 75% risk of developing migraine if both parents suffer from migraine
Alcohol, stress, anxiety, certain odors or perfumes, loud noises, bright lights, and smoking may trigger a migraine. Migraine attacks may also be triggered by
- Caffeine withdrawal
- Changes in hormone levels during a woman’s menstrual cycle or with the use of birth control pills
- Changes in sleep patterns
- Exercise or other physical stress
- Missed meals
- Smoking or exposure to smoke
- Sensory stimuli, such as bright lights, sun glare, and loud sounds
Migraines can be triggered by certain foods, including
- Processed, fermented, pickled, or marinated foods, as well as foods that contain monosodium glutamate (MSG) and nitrates (bacon, hot dogs, salami, cured meats)
- Baked goods, nuts, peanut butter, and dairy products (chocolate was once thought to be a trigger, but studies are showing it might actually be used as a treatment)
- Foods containing tyramine, which includes red wine, aged cheese, smoked fish, chicken livers, figs, and certain beans
- Produce (avocado, banana, citrus fruit, and onions)
According to data cited in the newly published guidelines,[1,2] migraine is both underrecognized and undertreated. Data also cited that almost 40% of people who suffer from migraine could benefit from preventive treatment, although only 12% actually take a preventive treatment.
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 available evidence on migraine prevention. The review did not address the magnitude of any given drug’s efficacy—only the strength of evidence backing their superiority relative to placebo. Among 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 serotonin receptor agonist, 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 top “effective” treatment for preventing migraine was the herbal preparation Petasites (butterbur). 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.
While no prescription is required for over-the-counter and complementary treatments, patients still should see a healthcare provider regularly for follow-up. Because migraines can get better or worse over time, patients 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.
Jill Shuman, MS, ELS
Published May 2, 2012
- Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults. Neurology. 2012;78:1337-1345.
- Holland S, Silberstein SD, Freitag F, et al. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults. Neurology. 2012;78:1346-1353.
- International Headache Society. The International Classification of Headache Disorders, 2nd edition. Cephalalgia. 2004;24(Suppl 1):1-160.
- Evans RW. Headaches during childhood and adolescence. In: Evans RW, Mathew NT, eds. Handbook of Headache. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:210.
- Cady RJ, Durham PL. Cocoa-enriched diets enhance expression of phosphatases and decrease expression of inflammatory molecules in trigeminal ganglion neurons. Brain Res. 2010;1323:18-32.
- Lipton RB, Bigal ME, Diamond M, et al; American Migraine Prevalence and Prevention Advisory Group. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68(5):343-349.