Migraine: Expanding our Tx arsenal
Beyond tried-and-true therapies are new therapeutic targets on the horizon—giving you a bigger toolbox to help patients abort and prevent migraine episodes.
PRACTICE RECOMMENDATIONS
› Offer treatment with a triptan to adult patients with moderate-to-severe episodic migraine. A
› Consider prescribing topiramate, divalproex sodium, metoprolol, propranolol, or the herbal, Petasites hybridum, for the prevention of recurrent episodic migraine that has not responded to a reduction in headache triggers. A
› Add onabotulinumtoxinA injection to your therapeutic toolbox as an effective preventive treatment for chronic migraine (≥15 headache days a month for 3 months). B
› Recommend magnesium and feverfew as adjunctive preventive treatments for migraine. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Just as for younger adults, mild symptoms can be managed effectively with acetaminophen. NSAIDs may be used as well, but carry increased risks of gastric bleeding and elevation in blood pressure.59 The use of triptans is acceptable for the appropriate patient, but should be avoided in patients with known vascular disease.60 Antiemetics present an increased risk of extrapyramidal adverse effects in the elderly and should be used with caution at the lowest effective dosage.59 Novel mechanisms of action make some of the newer agents potentially safer for use in older adults when treating acute migraine.
For migraine prevention in older adults, particular attention should be paid to reducing triggers and minimizing polypharmacy.
More and more, successful treatment is within reach
With many clinical trials evaluating novel drugs underway, and additional studies contributing to our understanding of nonpharmacotherapeutic approaches to migraine treatment, improved headache control may become increasingly common over the next few years.
CORRESPONDENCE
Kathryn McGrath, MD, Department of Family and Community Medicine, Thomas Jefferson University, 1015 Walnut St, Philadelphia PA 19107; Kathryn.mcgrath@jefferson.edu.
