Preventive Drugs for Migraine Identified in New AAN Guidelines

Updated guidelines for prevention of chronic migraine headache were unveiled during the 2012 Annual Meeting of the American Academy of Neurology.

New Orleans, LA—Updated guidelines for prevention of chronic migraine headache were unveiled during the 2012 Annual Meeting of the American Academy of Neurology and published simultaneously in Neurology on April 24, 2012.

The new guidelines include some changes from previous guidelines based on the totality of evidence. Topiramate is now recommended for prevention based on level A evidence, while gabapentin and verapamil have been downgraded and are no longer considered effective or probably effective.

“These guidelines tell us how good the evidence is for various drugs and over-the-counter (OTC) approaches to migraine prevention, not whether they may work. There may be drugs out there that work but have no clinical trial evidence,” explained Stephen D. Silberstein, MD, Jefferson Headache Center at Thomas Jefferson University in Philadelphia, PA.

Despite the availability of effective preventive treatments, they are underutilized by chronic migraine sufferers. About 38% of people who suffer from migraine could benefit from preventive treatment, but less than one-third of these people currently use them, Dr Silberstein said. Preventive treatments are taken every day, whether or not migraine is occurring, and they can reduce the frequency of attacks by more than 50%, he noted.

Based on existing evidence from 29 class I or II studies, the following prescription drugs have level A evidence to support their use for reducing the frequency and severity of migraine attacks: divalproex sodium, sodium valproate, topiramate (all antiseizure medications); and metoprolol, propranolol, and timolol (all beta-blockers). Lamotrigine, another antiseizure drug, was not found effective for migraine prevention.

Evidence for OTC and complementary medicine was also reviewed. The herbal preparation of Petasites (common name butterbur) was deemed effective for migraine prevention based on level A evidence. Treatments identified as “probably effective” based on level B evidence include the nonsteroidal anti-inflammatory drugs fenoprofen, ibuprofen, ketoprofen, naproxen, naproxen sodium, and subcutaneous histamine; and the complementary treatments magnesium, MIG-99 (feverfew extract), and riboflavin.

“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, stop their medications, or switch to a different medication. In addition, people need to keep in mind that all drugs, including OTC and complementary treatments, can have side effects or interact with other medications, which should be monitored,” Dr Silberstein commented.