Preventive (also called
prophylactic) treatment of migraine can be an important component of migraine management. Such treatments can take many forms, including everything from surgery, taking certain drugs or nutritional supplements, to lifestyle alterations such as increased exercise and avoidance of migraine triggers.
The goals of preventive therapy are to reduce the frequency, painfulness, and/or duration of migraine attacks, and to increase the effectiveness of abortive therapy.[1] Another reason to pursue these goals is to avoid
medication overuse headache (MOH), otherwise known as
rebound headache, which is a common problem among migraineurs. This is believed to occur in part due to overuse of pain medications, and can result in chronic daily headache.[2][3]
Standards for the conducts of trials of preventive medications have been proposed by the Task Force of the
International Headache Society Clinical Trials Subcommittee.[4]
Behavioral treatments
Exercise for 15–20 minutes per day may be helpful for reducing the frequency of migraine attacks.[5]
Diet,
visualization, and
self-hypnosis are also alternative treatments and prevention approaches. General dietary restriction has not been demonstrated to be an effective approach to treating migraine.[6]
Sexual activity has been reported by a proportion of males and females with migraine to relieve migraine pain significantly in some cases.[7]
Medications
A 2006 review article by S. Modi and D. Lowder offers some general guidelines on when a physician should consider prescribing drugs for migraine prevention:
Following appropriate management of acute migraine, patients should be evaluated for initiation of preventive therapy. Factors that should prompt consideration of preventive therapy include the occurrence of two or more migraines per month with disability lasting three or more days per month; failure of, contraindication for, or adverse events from acute treatments; use of abortive medication more than twice per week; and uncommon migraine conditions (e.g., hemiplegic migraine, migraine with prolonged aura, migrainous infarction). Patient preference and cost also should be considered.
...Therapy should be initiated with medications that have the highest levels of effectiveness and the lowest potential for adverse reactions; these should be started at low dosages and titrated slowly. A full therapeutic trial may take two to six months. After successful therapy (e.g., reduction of migraine frequency by approximately 50 percent or more) has been maintained for six to 12 months, discontinuation of preventive therapy can be considered.[1]
Preventive medication has to be taken on a daily basis, usually for a few weeks, before the effectiveness can be determined. Supervision by a
neurologist is advisable. A large number of medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next. Often preventive medications do not have to be taken indefinitely. Sometimes as little as six months of preventive therapy is enough to "break the headache cycle" and then they can be discontinued.
The most effective prescription medications include several drug classes.
Methysergide was withdrawn from the US market by
Novartis, but is available in Canadian pharmacies. Although highly effective, it has rare but serious side effects, including
retroperitoneal fibrosis.[15]
Methylergometrine remains available in the US and is an active metabolite of methysergide. It is thought to carry the same risks and benefits as methysergide but has not been widely studied in migraine.
Memantine, which is used in the treatment of Alzheimer's Disease, is beginning to be used off label for the treatment of migraine. It has not yet been approved by the FDA for the treatment of migraine.
Aspirin can be taken daily in low doses such as 80 mg. The blood thinners in ASA have been shown to help some migraineurs, especially those who have an aura.
Neurostimulation initially used implantable neurostimulators similar to pacemakers for the treatment of intractable chronic migraine[19][20] with encouraging good results. But the needed surgery with implantable neurostimulators is limiting the indication to severe cases.[21]
Transcranial magnetic stimulation
At the 49th Annual meeting of the
American Headache Society in June 2006, scientists from
Ohio State University Medical Center [22] presented medical research on 47 candidates that demonstrated that TMS — a medically non-invasive technology for treating depression,
obsessive compulsive disorder and
tinnitus, among other ailments — helped to prevent and even reduce the severity of migraine among its patients. This treatment essentially disrupts the aura phase of migraine before patients develop full-blown migraine attack.[23]
In about 74% of the migraine headaches, TMS was found to eliminate or reduce nausea and sensitivity to noise and light.[24] Their research suggests that there is a strong neurological component to migraine. A larger study will be conducted soon to better assess TMS's complete effectiveness.[25]
Biofeedback
Biofeedback has been used successfully by some to control migraine symptoms through training and practice.[26]Biofeedback helps patient to be conscious of some physiologic parameters to control them and try to relax. This method is considered to be efficient for migraine prevention.[27][28]
There have been major
pharmacological advances for the treatment of migraine headaches, yet patients must still endure symptoms until the medications take effect. Furthermore, often they still experience a poor quality of life despite an aggressive regimen of pharmacotherapy.[29]Migraine surgery techniques have proven most effective in selected patients, often resulting in permanent migraine prevention. The most effective appear to be those involving the surgical cauterization of the superficial blood vessels of the scalp (the terminal branches of the external carotid artery),[30] and the removal of muscles in areas known as "
trigger sites".[31][32][33]
Arterial surgery
Surgical cauterization of the superficial blood vessels of the scalp (the terminal branches of the external carotid artery) is only carried out if it has been established with certainty that these vessels are indeed the source of pain. It is a safe and relatively atraumatic procedure which can be performed in a day facility.[34]
Nerve decompression
Migraine surgery which involves decompression of certain
nerves around the head and neck may be an option in certain people who do not improve with medications.[35] It is only effective in those who respond well to
Botox injections in specific areas.[32][33]
Botulinum toxin injection
Botulinum neurotoxin (Botox) injections have been approved in the US and UK for prevention of chronic migraine,[36] but do not appear to work for episodic migraine.[37] Several
invasive surgical procedures are currently under investigation. One involves the surgical removal of specific muscles or the
transection of specific
cranial nerve branches in the area of one or more of four identified
trigger points.[32]
Closure of patent foramen ovale
There also appears to be a
causal link between the presence of a
patent foramen ovale (PFO) and migraine.[38][39] There is evidence that the correction of the
congenital heart defect, PFO, reduces migraine frequency and severity.[40] Recent studies have advised caution, though, in relation to
PFO closure for migraine, as insufficient evidence exists to justify this dangerous procedure.[41][42]
Alternative medicine
Acupuncture
Cochrane reviews have found that acupuncture is effective in the treatment of migraine.[43] The use of "true" acupuncture seems to be slightly more effective than sham acupuncture, however, both "true" and sham acupuncture appear to be at least similarly effective as treatment with preventative medications, with fewer adverse effects.[44]
Supplements
Butterbur
Native
butterbur contains some carcinogenic compounds, but a purified version, Petadolex, does not.[45] A systematic review of two trials totalling 293 patients (60 and 233 patients) showed "moderate evidence of effectiveness ... for a higher than the recommended dose of the proprietary Petasites root extract Petadolex in the prophylaxis of migraine."[46]
Cannabis
Cannabis was a standard treatment for migraine from 1874 to 1942.[47] It has been reported to help people through an attack by relieving the nausea and dulling the head pain, as well as possibly preventing the headache completely when used as soon as possible after the onset of pre-migraine symptoms, such as aura.[47][48]
Feverfew
The plant feverfew (Tanacetum parthenium) is a traditional herbal remedy believed to reduce the frequency of migraine attacks.[49] A number of clinical trials have been carried out to test this claim, but a 2004 review article concluded that the results have been contradictory and inconclusive.[49]
Manual therapy
A systematic review stated that chiropractic manipulation, physiotherapy, massage and relaxation might be as effective as
propranolol or
topiramate in the prevention of
migraine headaches; however, the research had some problems with methodology.[50]
References
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^Chronicle E, Mulleners W; Mulleners (2004). Mulleners, Wim M (ed.). "Anticonvulsant drugs for migraine prophylaxis". Cochrane Database Syst Rev (3): CD003226.
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^Steinman M, Bero L, Chren M, Landefeld C; Bero; Chren; Landefeld (2006). "Narrative review: the promotion of gabapentin: an analysis of internal industry documents". Ann Intern Med. 145 (4): 284–93.
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^Leone, M; Cecchini, AP; Franzini, A; Bussone, G (2011). "Neuromodulation in drug-resistant primary headaches: What have we learned?". Neurological Sciences. 32 (Suppl 1): S23–6.
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^Mosser, W.; Guyuron, B.; Janis, E.; Rohrich, J. (Feb 2004). "The Anatomy of the Greater Occipital Nerve: Implications for the Etiology of Migraine Headaches". Plastic and Reconstructive Surgery. 113 (2): 693–697, discussion 697–700.
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^Schürks, M; Diener, HC (2009). "Closure of patent foramen ovale in the prevention of migraine: Not enough evidence in favor". Nature Clinical Practice Neurology. 5 (1): 22–3.
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^Sarens, T; Herroelen, L; Van Deyk, K; Budts, W (2009). "Patent foramen ovale closure and migraine: Are we following the wrong pathway?". Journal of Neurology. 256 (1): 143–4.
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