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Evidence Based Migraine Prophylactic Drug Therapy

Published online by Cambridge University Press:  02 December 2014

W.J. Becker
W.J. Becker*
Affiliation:
University of Calgary, Calgary, Alberta, Canada
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Abstract

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Prophylactic drug therapy is a major component of overall migraine management. However, because we do not know how currently used prophylactic drugs exert their beneficial effects in migraine, their use is based primarily on clinical trials. In general, prophylactic drugs are indicated when patients have three or more attacks a month and symptomatic medication use alone is not satisfactory. The choice of drug must be individualized, and is influenced by contraindications, potential side effects, the need to treat associated symptoms like tension-type headache and insomnia, and drug cost. Whether an individual patient will respond to a given drug cannot be predicted, but there are varying degrees of scientific evidence supporting the use of each prophylactic drug in migraine. This evidence is best for metoprolol, divalproex, amitriptyline, atenolol, flunarizine and naproxen. Based on placebo-controlled crossover studies, it would appear that at least some prophylactic drugs exert the greater part of their prophylactic effects very quickly, and that these also disappear very quickly once the drug is stopped. This may not apply to all prophylactic drugs and more research is needed. More well designed clinical trials are needed to guide our use of migraine prophylactic drugs. Although clinical experience is useful, placebo responses and variations in the migraine tendency over time can make interpretation of this experience difficult. Major advances will likely only occur once the pathogenesis of migraine and the mode of action of the prophylactic drugs is better understood.

Résumé

RÉSUMÉ

La médication prophylactique est un aspect important du traitement de la migraine. Cependant, parce que nous ne savons pas comment les médicaments utilisés en prophylaxie de la migraine exercent leurs effets bénéfiques, leur utilisation est basée principalement sur des essais cliniques. En général, les médicaments utilisés en prophylaxie sont indiqués quand les patients ont trois accès de migraine ou plus par mois et que l’utilisation d’une médication symptomatique seule n’est pas satisfaisante. Le choix de la médication doit être individualisé et est influencé par les contre- indications, les effets secondaires potentiels, la nécessité de traiter les symptômes associés tels la céphalée de tension et l’insomnie, et le coût de la médication. Il est impossible de prédire si un patient répondra à tel ou tel médicament, mais il existe des données scientifiques de valeur inégale supportant l’utilisation de chaque médicament utilisé en prophylaxie de la migraine. Ces données sont plus probantes pour le métoprolol, le divalproex, l’amitriptyline, l’aténolol, la flunarizine et le naproxen. Il semble que, d’après les études en chassé-croisé contrôlées par placebo, certains médicaments exercent la plus grande partie de leur effet prophylactique très rapidement et que ces effets disparaissent également très rapidement quand le médicament est cessé. Cette observation ne s’applique peut-être pas à tous les médicaments utilisés en prophylaxie de la migraine et il faut faire plus de recherche sur ce sujet. D’autres essais cliniques bien conçus sont nécessaires pour guider notre utilisation de ces médicaments. Bien que l’expérience clinique soit utile, l’effet placebo et les variations dans le temps de la tendance à la migraine peuvent rendre difficile l’interprétation de ces expériences. Il est probable que des progrès significatifs ne seront accomplis que lorsque la pathogenèse de la migraine et le mode d’action des médicaments prophylactiques seront mieux connus.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 26 , Issue 3 , November 1999 , pp. 27 - 32
Copyright
Copyright © The Canadian Journal of Neurological 1999

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