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
In both studies, the risk of adverse drug events due to onabotulinumtoxinA was high and led to a significant rate of discontinuation.33,43 Despite this, onabotulinumtoxinA remains the only Food and Drug Administration (FDA)–approved treatment for chronic migraine, making it reasonable to consider for appropriate patients.
Acupuncture. A 2016 Cochrane review found benefit for patients using acupuncture compared with sham acupuncture.34 When acupuncture was compared with prophylactic agents such as beta-blockers, calcium-channel blockers, and anti-epileptics, however, there was no significant difference between the procedure and pharmacotherapy. Patients willing and able to try acupuncture might see a reduction in the overall number of headaches. Acupuncture has few adverse effects; however, long-term data are lacking.34
Exercise is not supported by robust data for its role as a prophylactic treatment. It is generally considered safe in most populations, however, and can be pursued with little out-of-pocket cost.35
Cognitive behavioral therapy (CBT). The AAN recommends CBT, relaxation therapy, and biofeedback therapy. Accessibility of these services remains limited for many patients, and cost can be prohibitive.16
Supplements used to help prevent migraine include the root of Petasites hybridus (butterbur), magnesium, vitamin B2 (riboflavin), Tanacetum parthenium (feverfew), and coenzyme Q10.16 Although the strength of evidence for these therapies is limited by small trials, their overall risk of adverse effects is low, and they might be easier for patients to obtain than acupuncture or CBT.
Continue to: Butterbur, in particular...
