Selecting Individualized Migraine Prevention Treatment
Once a neurologist has given a proper diagnosis, he or she should thoroughly review the patient’s profile to select the proper migraine prevention therapy. Gender, age, childbearing potential, and BMI are factors to consider when finding the best treatment for a given patient. “When you know you have to put someone on a medicine, you should know the side effects and be able to discuss them,” said Dr. McAllister. “I like to come up with a scatter plot in my head looking at increasing safety and tolerability on the y axis and increasing efficacy on the x axis…. If someone is really sensitive, you might want to aim towards the more tolerable medications.” For a patient with exceptionally painful headaches, it’s better to treat with highly efficacious drugs, despite their side effects, he added.
No migraine preventive therapy is pregnancy category A, said Dr. McAllister. None has been demonstrated safe for the unborn child. Nonsteroidal anti-inflammatory drugs are pregnancy category B and are recommended only during the first two trimesters. Metoclopramide and acetaminophen are also pregnancy category B. Category C drugs include amitriptyline, propranolol, verapamil, and onabotulinumtoxinA injections. Topiramate should not be used during pregnancy because it increases the risk for cleft palate in the child. Clear evidence indicates that divalproex is a teratogen.
Every patient with migraine should work with his or her doctor to find the most efficacious strategy for treatment. “What is the ideal migraine preventive drug? It should decrease the number of headache days or attacks, attenuate the intensity—of not just the pain, but the associated symptoms—render acute treatment, be effective, and have low or no side effects,” Dr. McAllister concluded.