Dopamine Antagonists Treat Migraine Effectively
Atypical Antipsychotics
Atypical antipsychotics are effective in migraine prophylaxis and generally are less sedating and less likely to produce movement disorders. Olanzapine has the best evidence in migraine among the atypical antipsychotics. The drug decreased the number of headache days and pain intensity in a study of chronic migraineurs who were refractory to more than four preventive agents. The study was retrospective and unblinded and had no placebo control, however. In practice, 5-mg to 10-mg doses are used at bedtime as a preventive treatment. A second study supported olanzapine’s efficacy as an abortive agent in daily doses of 2.5 mg to 5 mg. Neurologists may repeat dosing as needed to a daily maximum of 20 mg. “We have used 2.5 mg to 5 mg nightly for five to 10 nights to help break status migrainosus,” said Dr. Natbony.
Compared with olanzapine, quetiapine is less potent and entails a lower risk of movement disorders. In two studies of migraineurs who had failed standard preventive agents, quetiapine reduced headache frequency and severity, as well as the use of rescue medications. Doses administered in the study ranged from 25 mg to 75 mg daily.
The literature contains only case studies of aripiprazole in migraineurs. Three patients who received aripiprazole for psychiatric conditions reported spontaneous relief of migraine. One patient with medication overuse headache was treated successfully with aripiprazole. Doses range from 10 mg to 20 mg daily.
Like aripiprazole, ziprasidone has not been studied in randomized controlled trials. One case report described three patients with chronic daily headache who had improvements in headache frequency and severity with ziprasidone. For migraine prevention, neurologists can start with a dose of 20 mg bid and increase it to 80 mg bid, said Dr. Natbony. For acute treatment, doses range from 40 mg to 80 mg, with a maximum of 160 mg daily.
Comparative Efficacy
“The most beneficial oral medication appears to be olanzapine, followed by chlorpromazine” for acute treatment, said Dr. Natbony. IV prochlorperazine is also more effective than IV metoclopramide for acute treatment, “though metoclopramide should be considered as first-line treatment for prevention of a migraine attack and given during a prodrome,” she concluded.
—Erik Greb
