MICHAEL J. POLIZZOTTO, MD Camp Pendleton, California Submitted, revised, December 24, 2001. From the Family Practice Residency Program, Naval Hospital Camp Pendleton, Camp Pendleton, California. The opinions contained herein are those of the author and should not be construed as official or reflecting the views of the Department of the Navy or Department of Defense. The author reports no competing interest. Reprint requests should be addressed to Michael J. Polizzotto, MD, Department of Family Practice, Naval Hospital Camp Pendleton, Box 555191, Camp Pendleton, CA 92055-5191. E-mail: mjpolizzotto@cpen.med.navy.mil.
Besides use for acute treatment, NSAIDs are occasionally prescribed to prevent migraine. Naproxen sodium, the most frequently studied NSAID, shows a small but significant effect in overall improvement compared with placebo in several trials.39-41 Two of these studies showed a reduction in the number of severe headaches per week but no significant change in the total number of headaches per week.40,41
Some recent studies support the use of novel migraine prophylactics. One study of riboflavin (400 mg daily) showed a moderate reduction in migraine frequency.42 Achieving maximal therapeutic effect required 3 months of use. Another study found that 10 mg lisinopril daily can significantly reduce migraine frequency and severity when compared with placebo.43
TABLE 4 PROPHYLACTIC TREATMENT OPTIONS IN MIGRAINE
Strength of Recommendation
Treatment
Comments
A
Amitriptyline
Evidence for no significant difference versus propranolol32, 33
Considered effective by many experts; limited, poor-quality clinical trials (see text)
* Numbers needed to treat (NNT) in this column are for a 50% reduction in headache frequency compared with baseline; reported when available data permit.
Nonpharmacologic treatments
Although the data for nonpharmacologic migraine treatment are neither so extensive nor so rigorous as those for medications, some evidence is available. The Duke Center for Clinical Health Policy Research performed a comprehensive systematic review and meta-analysis of behavioral and physical treatments for migraine for the Agency for Healthcare Research and Quality.44 This review forms the evidence base for the USHC guideline in this area.45 The authors note that most studies were conducted on patients recruited at specialized headache centers; thus, caution should be exercised in generalizing the results to a primary care population.
The meta-analysis showed that cognitive–behavioral (including stress management) therapy, electromyelogram biofeedback, relaxation training, and thermal biofeedback combined with relaxation training are effective in migraine prophylaxis (LOE: B).44 An earlier meta-analysis concluded that the prophylactic benefit of combined relaxation and thermal biofeedback training was equivalent to the benefit obtained from propranolol.46 Because of limited or mixed evidence, no clear recommendations can be made with regard to acupuncture, cervical manipulation, hyperbaric oxygen, hypnosis, occlusal adjustment, or transcutaneous electronic nerve stimulation.45
Prognosis
Little evidence is available concerning the long-term prognosis of migraine, either with or without treatment. For many patients, migraine persists, but slowly decreases in frequency over a lifetime.47,48 For patients who respond well to prophylaxis, no data are available to help the clinician decide how long to continue using it. One small case series showed that while a few patients had a lasting reduction in the frequency of their migraines after stopping effective prophylactic medication, most experienced relapse.49
A subset of patients with migraine develops headaches of increasing frequency, often resulting in daily or continuous headaches. This syndrome has been known as transformed or malignant migraine. Many such patients use migraine medications on a daily basis. Although no controlled trials have been reported, the daily or near-daily use of most acute migraine medications (including acetaminophen, aspirin, dihydroergotamine, ergotamine, NSAIDs, opioids, and triptans) is believed capable of provoking medication-overuse headaches.50 Some of these patients can reduce the frequency of their headaches if they can break the cycle of medication use.47
Conclusions
Migraine headache is a common and disabling condition. The diagnosis often can be made on the basis of key findings in the patient’s history. A classic history, in combination with a normal neurologic examination, obviates head imaging. Available evidence clearly shows that effective methods for both acute and prophylactic treatment of migraine exist. The Figure contains an algorithm summarizing such treatment. Wider implementation of the USHC evidence-based guidelines by primary care physicians treating those with migraine should result in decreased pain and increased productivity for many patients.
FIGURE ALGORITHM FOR TREATMENT OF MIGRAINE
Acknowledgments
The author would like to thank John R. Holman, MD, MPH, for reviewing the manuscript and Anne J. O’Connor for her help in obtaining the references.
