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.