Migraine Prevention

Posted by Mark Abramowicz, M.D.

The April 24, 2012 issue of Neurology includes new guidelines for prevention of migraine headache, authored jointly by the American Academy of Neurology and the American Headache Society. Patients with frequent or severe disabling migraine headaches, especially those with menstrual or other predictable migraine attacks, should receive prophylactic treatment. The academies gave their highest rating for prescription drugs to the antiepileptics valproate and topiramate, along with 3 beta-blockers, and also to frovatriptan, a long-acting serotonin receptor agonist, for menstrual migraine.

When Treatment Guidelines from The Medical Letter reviewed this subject in February 2011, we looked at the same drugs and data and came to a slightly different conclusion. We noted that the antiepileptic drugs were increasingly being used for migraine prevention, but we found no evidence that that they are more effective than older drugs such as beta-blockers, tricyclic antidepressants and verapamil, and we were concerned about their more disturbing adverse effects, including cognitive impairment and hepatotoxicity.

The academies also evaluated over-the-counter medications for prevention of migraine and gave their highest rating to a dietary supplement, petasites (butterbur). Treatment Guidelines from The Medical Letter, which had access to the same data, did not recommend use of petasites, but did say it had, like some other dietary supplements, been reported to be effective in small randomized placebo-controlled trials. The Medical Letter has generally said of dietary supplements, which are not regulated by the FDA, that their purity and potency are suspect, and we do not really know what is in them.

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