New migraine guidelines focus on efficacy, prevention, and patient-centric approach

mdCurrent Conference Report: 64th American Academy of Neurology Annual Meeting

A large number of therapies are used prophylactically to prevent or abort migraine headaches but only 7 have proven efficacy, according to newly released guidelines.

The authors of the guidelines, issued jointly by the American Academy of Neurology (AAN) and the American Headache Society (AHS), acknowledged that other agents are likely to be effective but that the supportive data are weaker. They encouraged use of proven therapies as first-line strategies in migraine prevention.

The guidelines, which were published in the journal Neurology and presented at the 64th Annual Meeting of the AAN in New Orleans, Louisiana, United States, were based on a literature search of published studies in migraine treatment. Of the 7 therapies that met the strongest criterion of[s2If !is_user_logged_in()]…

[/s2If][s2If is_user_logged_in()] efficacy, which was defined as more than 1 randomized, multicenter trial, 3 were anticonvulsants (divalproex, valproate, and topiramate), 2 were beta blockers (propranolol and metoprolol) and 1 was a triptan (frovatriptan). The guidelines included a much longer list of agents with probable efficacy. The only agent examined that was declared ineffective was the anticonvulsant lamitrogene, because of failure to show benefit in 2 or more randomized trials.

Key Point:  Migraine prophylaxis is recommended for individuals with attacks that impair function, but only 7 therapies meet criteria for proven efficacy. These therapies, identified in new guidelines, can be considered first-line even though other therapies may be effective.

In India, the frequency and the patterns of migraine appear to be similar to those found in European and American populations. In a single-center survey of 166 consecutive migraine patients that was published in the Journal of the Association of Physicians of India (Panda et al. JAPI. 2005;53:111-115), the majority were women (72%), 65% had unilateral headache pain, 60% were disabled sufficiently by migraine attacks to affect ability to work, and the mean age of onset for the first attack was 21 years. Accompanying symptoms included nausea in 71%, photophobia in 81%, and phonophobia in 84%. Approximately 25% had a family history of migraine.

Identifying effective prophylactic strategies is important, because nearly 40% of migraine attacks are preventable, according to the lead author of the new AAN/AHS guidelines, Stephen D. Silberstein, MD, Jefferson Headache Center, Thomas Jefferson University, Philadelphia, Pennsylvania, United States. Prophylaxis is especially attractive in patients who experience neurologic symptoms such as weakness or dizziness that might pose a danger, but Silberstein said that he considers prevention useful in anyone with significant symptoms.

Although migraine attacks are not always preventable, many patients with recurrent migraines can recognize common triggers, detect early signs of an imminent attack, or both. The new guidelines provide physicians with a reasonable treatment algorithm of which strategies to try first. However, the authors of the guidelines emphasized that migraine is a heterogeneous disorder and response rates to a single agent vary markedly. They suggested moving to other agents that have been associated with activity against migraine if first-line therapies are ineffective.

Source: Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78(17):1337-1345.

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