Migraine: Prophylaxis and Medications

by Roy Strowd, MD

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    00:01 What about prophylaxis? Those are the treatments we use to abort the migraine once it's started, but the best treatment is to start something that prevents the migraine from coming on or reduces the severity once it's there.

    00:13 There are a number of medicines that we use both in pediatrics and for adult patients to prevent migraine attacks.

    00:20 Cyproheptadine is a really neat medicine.

    00:22 This is an antihistamine.

    00:24 It's frequently given in kids and sometimes we use it in adults.

    00:28 It's an antihistamine that can be quite effective as a prophylactic agent.

    00:32 We think about the TCAs, the tricyclic antidepressant medicines.

    00:36 These are things like amitriptyline and nortriptyline, which can be effective prophylactic agents.

    00:42 They can cause sedation we typically give them at night.

    00:44 A certain beta blockers can be effective as migraine preventive agents, as well as calcium channel blockers in patients who has sufficient heart rate and lack prior cardiovascular concerns with those medicines.

    00:58 And then anticonvulsants is the other category of medicines that we would consider for migraine prevention.

    01:03 And you see some of the agents here, topiramate and valproate acid are often agents that are considered initially.

    01:10 In addition, other complementary and alternative therapies can be considered.

    01:14 Magnesium is one that can be considered in a number of patients.

    01:17 We can use interventions botulism toxin and occipital nerve injections can be effective.

    01:22 And the latest medicines to be approved for treatment of migraine are the CGRP inhibitors or calcitonin gene-related peptide inhibitors.

    01:31 Calcitonin gene-related peptide is increased in patients with migraine and these inhibitors, manage that pathway and treat that underlying cause of migraine and can be quite effective in patients who have failed to respond to initial treatments.

    01:46 So let's walk through some of these.

    01:48 Beta blockers are some of the first medicines that we would consider in a migraine patient.

    01:52 There are some that have Level A evidence, the most evidence for their use and others that have slightly less evidence.

    01:57 Metoprolol and propranolol, particularly propranolol and timolol are agents that we commonly consider and have very good data to support their use.

    02:06 Typically, the most effective migraine prophylaxis medicine will reduce headaches by 50%.

    02:12 So all the days of the month where the patient has a headache, these medicines will reduce those by 50% or cut the severity of the headache in half.

    02:20 Level B beta blockers include nadolol and atenolol.

    02:25 How about calcium channel blockers? There's less evidence to support calcium channel blockers but we use these clinically very frequently.

    02:32 When you think about the calcium channel blockers, there's really two categories.

    02:35 Verapamil is very good for use in migraine in particularly complicated migraine where patients may have neurologic symptoms.

    02:43 We don't use the Diltiazem.

    02:44 These are less effective for migraine prevention.

    02:49 And then antidepressants.

    02:50 Antidepressants can be quite effective and we think about the TCA is often initially when managing patients amitriptyline or nortriptyline.

    02:58 Nortriptyline tends to be good for patients who have a sleep dysfunction.

    03:01 It can cause sleep, it can promote and it can cause patients to want to go to sleep, it can promote sleep, it can also cause problems with dry mouth, dry eyes, constipation, and those are symptoms that we have to to monitor and adjust dose for.

    03:19 Nortriptyline tends to be a little better tolerated than amitriptyline and is often used initially.

    03:25 And then the SSRIs, selective serotonin reuptake inhibitors can be used and with variable effectiveness in patients.

    03:33 The antidepressants we frequently use to manage migraine and prevent migraine Level A evidence supports the use of valproic acid and topiramate.

    03:41 Topiramate is a commonly used medicine.

    03:42 One of the side effects we think about is weight loss which can be helpful in some migraineurs.

    03:48 And valproic acid can be a very effective medicine.

    03:52 Valproic acid is a potential teratogen and so we don't use it in women of childbearing age.

    03:58 And Level U evidence, there's less evidence to support the use of gabapentin, pregabalin, or levetiracetam, though you will see these used variably in the clinic.

    04:07 There are other medicines that can also be used and have varying degrees of evidence.

    04:11 The ACEs and ARBs, ACE inhibitors and angiotensin receptor blockers, lisinopril and candesartan have been studied and then the antihistamine cyproheptadine as I discussed.

    04:23 What about complimentary and alternative therapies? These are agents that we also use variably for selected patients.

    04:30 Level A evidence supports the use of butterbur as an effective agent for migraine prevention.

    04:35 Riboflavin and magnesium, I will frequently use and Co-Q-10 has also been studied.

    04:42 Botulism is a newer treatment.

    04:44 Though at this point well studied and well used in the clinic for chronic daily migraines and that's migraine days more than 15 days in the month.

    04:54 There's somewhat individualized dosing based on where the Botox is delivered.

    04:58 For patients who have really prominent frontal headaches.

    05:01 We give injections in the frontal and lateral aspects of the head as you can see here.

    05:05 For posterior predominant headaches, we look at the posterior compartment and some patients have both prominent frontal and posterior headaches, we would treat both areas.

    05:14 And here you can see a view laterally of where Botox would be administered and then inferiorly and even in the trapezius muscles, we can see benefit of Botox injections and those reasons and this is approved for patients with chronic daily migraine headaches that are refractory to other first line interventions.

    05:33 Botulism toxin tends to be very well tolerated.

    05:36 There is very limited spread of the toxic effects.

    05:40 We don't tend to see other Botox effects elsewhere in the body.

    05:44 We can see bruising, mild ptosis, particularly if the injection is given around the eyelid.

    05:50 Transit muscle soreness can be seen and transit muscle weakness is rarely reported but can be seen in patients receiving Botox, localized Botox.

    About the Lecture

    The lecture Migraine: Prophylaxis and Medications by Roy Strowd, MD is from the course Headache.

    Included Quiz Questions

    1. Beta-blockers
    2. Serotonin reuptake inhibitors
    3. Lithium
    4. Alpha-blockers
    5. Ergotamines
    1. The agent decreases the number or severity of migraine headaches per month by 50%.
    2. The agent decreases the number or severity of migraine headaches per month by 75%.
    3. The agent decreases the number or severity of migraine headaches per month by 10%.
    4. The agent decreases the number or severity of migraine headaches per month by 25%.
    5. The agent decreases the number or severity of migraine headaches per month by 90%.
    1. Butterbur
    2. Calcium
    3. Vitamin D
    4. Vitamin B6 (Pyridoxine)
    5. Coenzyme Q10

    Author of lecture Migraine: Prophylaxis and Medications

     Roy Strowd, MD

    Roy Strowd, MD

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