Treatment Options for Migraine Headache

Prevention of Migraine Headache

Migraine headaches can be very disabling and can cause significant impact on quality of life, including missed work days, reduced productivity, interruption of academic studies, interruption of social activities, and physical discomfort. The American Headache Society (AHS) notes that some people with frequent migraine headaches are at risk for progression to chronic headache and that preventive therapy could alter this progression.

There are several modalities that may be used to help prevent migraine headaches, including:

  • Education
  • Medication
  • Complementary Therapy

Education

Education is important regarding avoidance of triggers and situations that may be conducive to headache onset, such as avoiding triggers, reduce estrogen medication, resting in a dark room when you feel a headache beginning. Just as important are positive behaviors that may help prevent migraine headaches, such as exercising, eating, and sleeping regularly.

Medication

The consensus of the AMPP (American Migraine Prevalence and Prevention) study conducted by the National Headache Foundation suggested the following guidelines for initiation of medication for prevention of migraine headache:

Prevention is recommended for:

  • Six or more headache days per month
  • Four or more headache days per month with at least some impairment
  • Three or more headache days per month with severe impairment or requiring bed rest

Prevention should be considered for:

  • Four to five migraine days per month with normal functioning
  • Three migraine days per month with some impairment
  • Two migraine days per month with severe impairment

No prevention is indicated for the following:

  • Less than four headache days per month with no impairment
  • No more than one headache day per month even with impairment

According to the U.S. Headache Consortium Guidelines, prevention of migraine headache with drugs should be considered under the following conditions:

  • Presence of 2 or more migraine headaches per week or a pattern of increasing attack frequency over time
  • Recurring migraines that interfere with daily life despite acute treatment
  • Failure of acute treatment, contraindication, or adverse reaction to acute treatment
  • Use of medication for acute headache more than twice a week
  • Patient preference for preventive treatment

The goals of preventive treatment include:

  • Reducing the frequency of headaches by at least 50%
  • Reducing the severity and duration of headaches
  • Increasing responsiveness to medication for acute headaches
  • Increasing quality of life of the patient

Although preventive medication can reduce the frequency of migraine headache by at least 50%, it is estimated that preventive treatment is used by less than 50% of migraine sufferers.

Principles of migraine prevention with medication include:

  • Begin with the lowest dose possible and gradually increase until the desired effect is achieved, which may take 2-6 months. Medications should have highest effect and least side effects.
  • Patients should understand that a considerable amount of time may lapse until the medications are effective.
  • Realistic expectation of the patient regarding success of preventive therapy - i.e. that medication reduces frequency and severity of headaches but does not completely eliminate them. Also, headaches that occur while on preventive treatment can be successfully treated.
  • Patients should understand potential side effects of medications and should understand when to contact their physician
  • Patients should understand all aspects relating to preventive management, such as when to take medications, when to call physician, keeping appointment, or notifying doctor when they feel they have achieved significant improvement
  • Medication should be tapered slowly as the patient improves and should be reevaluated if headaches begin to recur.

First-line medications that are recommended by the U.S. Consortium on Headache guidelines for prevention include:

  • Beta Blockers - propranolol (Inderal) and timolol (Blocadren) have been approved by the U.S. Food and Drug Administration for prevention for migraine headache. They are contraindicated in patients suffering from depression, for athletes due to reduced exercise tolerance, for patients with congestive heart failure, asthma, hypoglycemia, and hypotension. Adverse effects include:

    • Drowsiness
    • Sleep disorders
    • Depression
    • Memory disturbance
    • Hallucinations
    • Nightmares
    • Orthostatic hypotension (drop in blood pressure when changing positions, such as sitting to standing)
    • Bradycardia - slow heart beat

  • Antidepressants - amitriptyline is the only tricyclic antidepressant (TCA) with consistent evidence of efficacy in headache prevention. Tricyclic antidepressants are best used for patients with depression or sleep disturbances. Another class of antidepressants, selective serotonin reuptake inhibitors (SSRIs), has fewer side effects but has not proven to be effective for prevention of headaches. If a patient cannot tolerate the side effects of amitriptyline, they can try a difference TCA to see if it is more tolerable. Side effects of TCAs include:

    • Drowsiness
    • Increased appetite and weight gain
    • Orthostatic hypotension

  • Calcium Channel Blockers - studies support the efficacy of flunarizine but it is not available in the U.S. Verapamil (Bosoptin) is particularly well suited for people with comorbid conditions such as hypertension or people with other comorbid conditions for whom beta blockers are contraindicated, such as asthma. Calcium channel blockers also appear to be effective for people who experience prolonged aura with the migraine headaches. The most common side effect of verapamil is constipation.

  • Anticonvulsant drugs - these include divalproex sodium (Depakote), and topiramate (Topamax), both of which have been approved by the FDA for prevention of migraine headache. Topiramate has been studied extensively. It is effective within two weeks of initiating treatment and the benefit increases for several months. Anticonvulsant drugs are particularly helpful for patients with a comorbid history of bipolar disorder, anxiety disorder, or epilepsy. Anticonvulsants have a high rate of adverse side effects and drug levels must be carefully monitored. Adverse effects include:

    • Sedation, hair loss, tremor, cognitive changes, hepatotoxicity, nausea/vomiting, and indigestion (valproate)
    • Weight loss, paresthesia, cognitive changes (topiramate)
    • Dizziness and drowsiness (gabapentin)
    • Interference with oral contraceptives (antiepileptic drugs)

The U.S. Consortium on Headache notes that there is fair evidence of effectiveness for prevention of migraines for the following medications::

  • Gabapentin (Neurontin)
  • Naproxen sodium (Anaprox)

  • Botulinum Toxin A (Botox) injected into various point of the face and neck. Results of studies regarding efficacy are mixed and it is used by some physicians only after all other medications have failed. Side effects are mild and temporary and include:

    • Frontal facial weakness
    • Ptosis (drooped eyelids)
    • Pain at injection sites

Nonsteroidal anti-inflammatory drugs are helpful for preventing menstrual migraines if commenced several days before menstruation and continued for a few days after the period begins.

Factors that play a role in determining which preventive agent to choose include:

  • Comorbidities of the patient
  • Determining if there is a preventive medication that can prevent migraines while at the same time treating the comorbid condition
  • Consideration of the drugs being taken by the patient
  • Patient preference in terms of adverse effects they are willing to tolerate, (e.g. weight changes, fatigue, etc.)
  • Consideration of pregnancy or plans to conceive
  • Consideration if a woman is taking contraceptive medication since contraceptives may impact the frequency of migraine headaches and some migraine-preventive medications may reduce the effectiveness of the contraceptives.

In general, preventive medications are given one at a time and are not combined since combinations are associated with more adverse effects and data is limited regarding the efficacy of two or more drugs in migraine prevention.

Complementary Therapies for Migraine Prevention

In 2000, the US Headache Consortium concluded that the following complementary medicine therapies are effective for migraine prevention and may be used as adjunct therapies while receiving other conventional treatments:

  • Relaxation training
  • Thermal biofeedback combined with relaxation training (stress dilates blood vessels and biofeedback helps to reduce blood vessel dilation by measuring skin temperature)
  • Electromyographic biofeedback (reducing muscle tension)
  • Cognitive-behavioral therapy

The American Headache Society (AHS) notes that complementary therapies are not as strictly regulated by the FDA as prescription medication and many of these therapies are called "supplements". There is a lack of standardization regarding the purity of content of herbal supplements as well as the consistency of batches that are sold. In addition, many lack rigorous clinical trials and are based on small numbers of patients. The AHS has assigned Grade B to herbal supplements meaning that there is limited evidence from a single randomized control trial or nonrandomized control trial, or several trials with inconsistent results.

Some natural supplements that are under investigation for the treatment of migraine headache include:

  • Butterbur
  • Magnesium

  • Feverfew - adverse effects include:

    • Sore mouth and tongue
    • Oral ulcers
    • Swollen lips
    • Loss of taste
    • Abdominal pain
    • Gastrointestinal disturbance
    • Joint stiffness
    • Increased headaches
  • Riboflavin
  • Coenzyme Q10

To read more about complementary therapies for prevention of migraine headache, please click on the following link: http://www.ncbi.nlm.nih.gov/sites/entrez?Db=PubMed&Cmd=ShowDetailView&TermToSearch=16732849&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.PubmedResultsPanel.PubmedRVDocSum