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“…And then a throb hits you on the left side of the head so hard that your head bobs to the right…

There's no way that came from inside your head, you think. That's no metaphysical crisis. God just

punched you in the face.” --Andrew Levy,

A Brain Wider Than the Sky: A Migraine Diary

Migraine Prevention

LT Sara Pope, MD

7 February 2013

Objectives

• Briefly reviewed treatment of migraines

• Explored the importance of prophylaxis

• Assessed when to start prophylaxis

• Discussed treatment types

Migraines: In Brief

• Common, complex and recurrent

• >30 million people have 1+ migraines/year

• 13% prevalence, 75% female

• 80% have a 1st degree relative with a history

• Environmental, behavioral triggers

Migraines: Sensitive CNS?

• Intracranial vasoconstriction + rebound dilation

• Neurogenic process w/2°changes in cerebral perfusion

–Classic: +AURA, gradual, unilateral, pulsating, +sensory

–Common: NO AURA, episodic vs. chronic

True Migraine?

• Head pain + nausea + sensory sx

• >4 h, <72h

• Starts young, rare >50 yo

• Common in reproductive years

• Predictable triggers

• Red flags

Why Prophylaxis?

• Reduce frequency, severity and duration

• Improve responsiveness to acute tx

• Improve function, reduce disability, +QOL

• Reduce costs

• Only 13% on preventive therapy

When to Start?

• Recurrent, interfere w/ADL’s despite tx

• >4 attacks/month

• Contraindications or failure/overuse of acute tx

• Adverse events to acute tx

• Hemiplegic, basilar, prolonged aura, infarction

• Menstrual: mini-prophylaxis

How?

• Several medications

• Varied mechanisms of action

• No ‘gold standard’, pt specific

• Success: reduction in migraine frequency by 50% in first 3 months

What does the evidence say?

Small Groups

Three Groups

Three Medication Categories

Three Teaching Points

Three Cases

Anti-Hypertensives

Anti-Hypertensives

• Propanolol, metoprolol,timolol: Effective

• Verapamil, nimodipine: Insufficient

• Lisinopril, candesarta: Possibly effective

• Telmisartan: Possibly not effective

Anti-Convulsants

Anti-Convulsants

• Topiramate: Effective, as good as BB, VA, TCA

• Divalproex, valproate: Effective

• Gabapentin: Insufficient

• Lamotrigine, oxcarbazepine: Ineffective

Anti-Depressants&

Others

Anti-Depressants

• Fluoxetine: Limited, conflicting data

• Venlafaxine: Probably Effective

• Amitriptyline: Probably Effective, as good as topiramate, maybe Venlafaxine

Others…

• Triptans• Botox• Butterbur• Co-enzyme q10• Feverfew• Magnesium• Methylsergide• Riboflavin

• Acupuncture• Relaxation,

biofeedback• CBT• Hypnosis• TENs• Hyperbaric

oxygen

Principles of Prophylaxis

• Start low, go slow

• Adequate trial in duration, dosage

• Avoid overuse: analgesics, opioids, triptans

• Caution: women of child bearing age

• Address expectations, preferences, side effects, commitment

• Slowly taper w/improvement, recommend 6-9 months

Objectives

• Briefly reviewed treatment of migraines

• Explored the importance of prophylaxis

• Assessed when to start prophylaxis

• Discussed treatment types

Questions?