Review: Migraine frequency and severity guide symptomatic and prophylactic therapy
ACP J Club. 1997 Nov-Dec;127:69. doi:10.7326/ACPJC-1997-127-3-069
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• Correction: Review: Migraine frequency and severity guide symptomatic and prophylactic therapy
Pryse-Phillips WE, Dodick DW, Edmeads JG, et al. Guidelines for the diagnosis and management of migraine in clinical practice. Can Med Assoc J. 1997 May 1;156:1273-87.
To assess evidence for guidelines for the diagnosis and treatment of migraine.
Studies were identified by searching MEDLINE (1966 to 1996) using the keywords migraine, human, English, therapy, sumatriptan, and clinical trial. Texts on headache were also reviewed.
Studies on the management of migraine were selected according to their level of evidence: randomized controlled trials, randomized trials (not controlled), cohort studies, case-control studies, and case series.
Data were extracted on type of treatment, specific drugs, formulation, method of administration (oral, intravenous, injection, inhalation, and suppository), dosage, side effects, and level of evidence.
For symptomatic treatment, migraines were classified as mild, moderate, severe, and ultra-severe. In aborting mild migraine, randomized controlled trials have shown that the nonsteroidal anti-inflammatory drugs (NSAIDs) acetylsalicylic acid, ibuprofen, and naproxen were more effective than placebo. In aborting moderate migraine, NSAIDs, sumatriptan, and dihydroergotamine were more effective than placebo. For severe migraine, either dihydroergotamine or sumatriptan as first-line agents and chlorpromazine and prochlorperazine as alternatives were supported by randomized controlled trials. Ketorolac and dexamethasone can be used in refractory cases. Dihydroergotamine preceded by metoclopramide was considered the primary treatment for aborting ultra-severe migraine. Prophylactic therapy should be considered when migraine impairs quality of life and is not adequately treated by symptomatic agents. Prophylactic therapies include β-blockers (atenolol, metoprolol, nadolol, and propranolol), calcium channel blockers (flunarizine and verapamil), serotonin receptor antagonists (methysergide and pizotyline), tricyclic antidepressants (amitriptyline and nortriptyline), antiepileptics (divalproex, sodium valproate, and valproic acid), and NSAIDs (naproxen, for premenstrual migraine only). The presence of comorbid conditions should help guide the selection of prophylactic therapy.
Effective treatments exist for the prevention and treatment of migraine. The severity of a migraine should be taken into account for appropriate symptomatic treatment. Prophylactic therapy should be considered for patients who have frequent or severe episodes.
Source of funding: Glaxo Wellcome Inc.
For article reprint: Dr. W.E. Pryse-Phillips, Division of Neurology, Health Sciences Centre, St. John's, Newfoundland A1B 3V6, Canada. FAX 709-737-6656.
Pryse-Phillips and colleagues provide user-friendly, evidence-based guidelines for the diagnosis and management of migraine headaches. The authors provide useful information to improve the accuracy of migraine diagnosis and mention the important caveats that migraine episodes can be bilateral in up to 30% to 40% of cases and that > 50% of patients with migraine report nonthrobbing pain during some episodes. The authors do not recommend routine use of electroencephalography, neuroimaging, and lumbar puncture in migraine diagnosis but provide clinical criteria that should prompt such investigations.
Pryse-Phillips and colleagues outline recommendations for symptomatic and prophylactic management and point out that no published studies have shown the efficacy of acetaminophen in acute migraine, that sumatriptan is not effective during the aura phase of migraine with aura, and that dihydroergotamine has a longer duration of action and thus is associated with a lower headache recurrence rate than sumatriptan. The importance of limiting the number and frequency of medications used cannot be overemphasized given the potential complication of analgesic overuse and chronic daily headaches (1).
All prophylactic medications reviewed have a potential role in migraine management. Given the number of pharmacologic options available, however, it may be worthwhile to hone one's skills in using 3 or 4 different medications, each from a different class (e.g., propranolol, verapamil, amitriptyline, or depakote). Except in the most refractory cases, one should be able to achieve adequate headache control by titrating upward to an effective tolerable dose and, if necessary, by combining agents from different classes.
It must be stressed that migraine management is a team approach that often requires patience and trial-and-error. Although complete cure is rare, substantial human and economic benefits can be achieved by judicious application of the current best evidence found in this guideline. Finally, the role of nonpharmacologic treatments in migraine management should not be forgotten; the evidence for this will be codified into guidelines by the same authors at a later date.
Robert Holloway, MD, MPH
University of RochesterRochester, New York, USA