Helia Hemasian MD assistant professer of neurology I sfahan university of medical science Background Migraine is a frequent disease Therefore guidelines for the prevention ID: 1044175
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1. prophylactic treatment of migraine headacheHelia Hemasian MDassistant professer of neurologyIsfahan university of medical science
2. BackgroundMigraine is a frequent disease Therefore, guidelines for the prevention by drug treatment or behavioral therapy have great practical importance.migraine prevention is multifaceted and includes lifestyle modifications, avoidance of risk factors for developing migraine attacks, and, when indicated, medications,neurostimulation, and behavioral therapiesThe choice of a migraine prophylactic drug should be based on the attack frequency (episodic vs. chronic), comorbid diseases and the patient’s individual needs.Drug therapy should be supplemented by non medication procedures of behavior therapy (e.g. relaxation procedures).Regular aerobic endurance sport is recommended
3. LIFESTYLE MODIFICATION AND TRIGGER AVOIDANCEadherence and persistence with therapy.medications, nutraceuticals, neurostimulation, and behavioral therapiesavailable therapies and those in the pipelineInterventional procedures for migrainetherapyspecial situations in migraine treatment
4. LIFESTYLE MODIFICATION AND TRIGGER AVOIDANCEIt is generally believed that fluctuations/changes in a person’s usual daily routine can trigger migraine attacksaerobic exercise can provide benefits to headache patterns 150 min per week of moderate-intensity aerobic exercise (generally divided among 3 to 5 sessions)Foods that are commonly cited as triggers include those with monosodium glutamate, those with nitrates (processed meats), aged cheeses, and artificial sweeteners.Caffeine overuse and caffeine withdrawal are both associated with headaches and migraine.1
5. Avoiding Factors That Increase Risk of Developing Migraineobesity, sleep disorders, psychiatric disease, the frequent use of abortive migraine medications, female sex, lower socioeconomic status, comorbid pain disorders, major life events, history of head or neck injuryIdentification and treatment of sleep disturbances is recommendedObesity is associated with a moderately higher risk of migraine and with an increasing number of headache days among those with migraine.Weight loss may be associated with reductions in headache frequency and severity.1
6. Indication for treatment for migraine preventionis based on the frequency of migraine attacks, reduction in quality of life and the risk of medication overuse.3 or more migraine attacks per month with negative impact on quality of life; that are not responsive to acute treatmentsAt least 6 to 8 headache days per month even if acute medications are effectiveMigraine attacks longer than 72 hPatients who cannot tolerate the side effects of acute therapyintake of analgesics or migraine drugs on 10 days per month;Complicated migraine attacks (e.g. hemiplegic) or long-lasting auras; Following migrainous brain infarction when other causes of stroke can be excluded.2
7. The decision of which preventive therapy to recommend is based onThe level of evidence that a specific therapy is effective the likelihood of a patient tolerating the therapyits safety profile and costpatient comorbiditiesPotential interactions with other therapies that the patient usesthe patient’s prior experiences with similar or related therapies (eg, choose a medication that works differently than medications that were previously ineffective or not tolerated)and patient preferences 2
8. Aim of treatmentThe aim of drug treatment is a reduction of frequency, severity and duration of the attacks and the prevention of medication overuse headache.Migraine prevention is considered effective when it achieves a reduction of the migraine attack frequency of 50% or more.The effectiveness can be evaluated 2 months after reaching the highest tolerated dose.Medications for migraine prevention should be titrated slowly and taken in the evening2
9. Medications and nutraceuticalsrecommended for usetopiramatepropranolol, nadolol, metoprolol, timololAmitriptylinegabapentinCandesartandivalproex sodium, sodium valproateFlunarizine , verapamilvenlafaxine Lisinoprilcoenzyme Q10Magnesium citrateRiboflavinOnabotulinumtoxinA erenumab.3
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12. Beta blockersan average 44% reduction of migraine activity for propanolol in a dose of 160 mgThe evidence for other beta blockers is less-well documented. Bisoprolol was significantly superior to placebo in one study and in a further study just as effective as metoprolol.Positive studies are also available for timolol, atenolol and nebivolol Acebutolol, alprenolol, oxprenolol and pindolol are ineffective in the prevention of migraine4
13. calcium channel blockersFlunarizine is the only CCB which showed a significant effect in migraine prevention.The effect strength of flunarizine does not differ from that of metoprolol, but there are more frequently side effects nifedipine and nimodipine are ineffective. Verapamil was only tested in very small studies and is probably also ineffective.3
14. Anti Hypertensive agentsACE-inh and ARBs: Lisinopril and telmisartan showed a significant reduction in attack frequencyCandesartan was also superior to placeboThere are no large dose-finding studies for other ACE-inhibitors or ARBs.3
15. TopiramateThe efficacy of topiramate could be documentedThe initial dosage should start slowly with 2 * 12.5 or 2 * 25 mg and if necessary up to 2 *100mg per day as final target dose.Limiting factors of topiramate are cognitive side effectsThere is also evidence for the efficacy of topiramate in medication-overuse headache and in chronic migraineIn combination with nortriptyline, topiramate was effective in patients who did not respond to monotherapy3
16. Valporic acidValproic acid showed a marked reduction in migraine attack frequency but not intensityDue to its teratogenic properties, valproic acid should not be prescribed for women of childbearing potential Valproic acid is not effective in migraine prevention in children and adolescents.3
17. Other AEDsA reduction in the frequency of migraine attacks could be demonstrated for lamotrigine and levetiracetamin smaller, not placebo-controlled studies in patients with migraine. Lamotrigine is effective in the reduction of the frequency of migraine attacks in migraine with, but not without aura.Zonisamide showed similar good effectiveness as topiramate in a comparison study3
18. AntidepressivesAmitriptyline is the drug of first choice in the United StatesAmitriptyline has efficacy comparable to that of topiramateAmitriptyline is also effective in chronic migraineThe best effect was achieved after administration for 4 months.Serotonin reuptake inhibitors (SSRIs) are ineffective in the prevention of migraine.Venlafaxine is a serotonin and noradrenalin reuptake inhibitor (SSNRI), for which two smaller controlled positive studies are available3
19. Migraine prevention with medications with a lower evidence levelASA in a low dose of 100–300 mg/day has a moderate migraine preventive effectMagnesium in a dose of 10 mmol/ day was not effective A dose of 24 mmol/day(2*300) magnesium was, however, effectivehigh-dose vitamin B2 (daily dose 2 200 mg).coenzyme Q10 (daily dose 3 100 mg) Onabotulinumtoxin A is probably not effective in the therapy of episodic migraine.Onabotulinumtoxin A is effective in the therapy of chronic migraine3
20. Combination Therapycombination therapy was not superior to monotherapyA combination of treatments can be used for migraine prevention when a patient has inadequate response to a single therapyit is recommended that the medications work via complementary but different mechanisms of actionCombinations of beta blockers or flunarizine with topiramate, as well as valproate and beta blockers were effective.3
21. Therapies in the Pipelineseveral other migraine preventive therapies are in the pipeline including CGRP monoclonal antibodiesResults from Phase 2 and Phase 3 clinical trials of CGRP monoclonal antibodies demonstrate their efficacy, tolerability, and safety for prevention of episodic migraine and chronic migraineErenumab has recently received FDA approval for the prevention of migraineother migraine preventive therapies that are under investigation include small-molecule CGRP antagonists Therapies that target pituitary adenylate cyclase-activating polypeptide, kappa opioid receptors, nitric oxide synthase, orexins, and glutamate3
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23. Depression4Amitriptyline is especially suited for migraine prevention in patients with depression, whereby the dose must be within the antidepressive-effective range (75–150 mg/day).There is a relative contraindication for the use of beta blockers,flunarizine and topiramate in the presence of depression
24. Prevention of aura4Lamotrigine is not effective in the reduction of migraine attack frequency but it may reduce the frequency of migraine attacks with aura. Flunarizine can result in a reduction in frequency of both auras and migraine attacks. In individual cases, topiramate is also effective.
25. Migraine prevention in children and adolescents4flunarizine (5 mg/day) in children hasbeen proven. Topiramate 15–100 mg/day was effective.For propranolol, there is some evidence of effectiveness. Valproic acid is not effective in children and adolescents
26. Migraine prevention in pregnancy4Metoprolol, propranolol and amitriptyline are considered as possible drug prevention in pregnancyMagnesium is not recommendednon-pharmaceutical measures such as relaxation therapy, biofeedback and acupuncture should be applied
27. Prevention of menstrually associated migraine4When menstruation is normal, options for short-term prevention include the administration of naproxen or a triptan with longer half-lifestarting 2 days prior to the expected start of migraine for a total of 6 to 7 days.the best evidence is for frovatriptan 2 *daily 2.5 mg/naproxen 2* 500 mgThe strategy of percutaneous oestrogen administration, can no longer be recommendedcontinuous administration of a combined oral contraceptive (COC) as a preventive measure can be considered
28. Adherence and Persistence With Preventive TherapyAdherence to oral migraine preventive medications ranges from only 26% to 29% at 6 months and 17% to 20% at 12 months.Although the reasons for low adherence vary, side effects and lack of efficacy are commonly cited. Thus, it is important to educate patients It is essential to determine the patient’s level of adherence with the treatment before determining that the therapy was ineffective.5
29. optimal timing for stopping preventivetherapyWhen oral preventive therapy with a target therapeutic dose is ineffective after 2 to 3 months, it should be discontinued or the dose should be increasedEffective preventive therapy should be continued for at least 3 to 6(6-12) months before tapering the dose or discontinuing the treatmentAt least two to three treatments with onabotulinumtoxinA are suggested prior to determining its efficacy for treatment of chronic migraine5
30. Interventional procedures for migrainetherapy6Closure of a patent foramen ovale is not recommendedThe effectiveness of the transection of the corrugator muscle or other pericranial muscles is not confirmedthe role of occipital nerve blocks in episodic migraine remains unclear;there is evidence of a possible prophylactic efficacy in chronic migraine.
31. See the IHS website for more informationand to join onlineBelong to the International Headache Society (IHS)Headache/neurology specialists from Iran can join free of charge as an Associate MemberOnline access to Cephalalgia Online access to The Neuroscientist Access to the IHS Online Learning CentreEarly access to IHS International GuidelinesBenefit from key Exchange Programmes and AwardsFellowships / ScholarshipsTravel GrantsVisiting Professors Headache Master Schoolswww.ihs-headache.orgTo advance headache science, education and management, and promote headache awareness worldwide.Free of charge Associate Membership