Magazine article Clinical Psychiatry News

Migraine Prevention: Tailor Choice to Patient

Magazine article Clinical Psychiatry News

Migraine Prevention: Tailor Choice to Patient

Article excerpt

CANCUN, MEXICO -- So many medications are available for migraine prevention that choosing the right one requires persistence by the physician as well as the patient, Dr. Todd D. Rozen said at a symposium sponsored by the American Headache Society.

"We have antihypertensive, we have antidepressants, we have antiepileptic, we have natural compounds," said Dr. Rozen of the Michigan Head-Pain and Neurological Institute, Ann Arbor. "The reason mainly is that one drug is not going to work in every migraineur."

There are probably 30 forms of migraine, Dr. Rozen said, with no way to determine a priori which preventive agent will work for a given individual. The treating physician must rely on a set of principles to guide medication choices.

Some old dogmas have fallen by the wayside recently. For example, it used to be thought that patients should be placed on migraine prevention only if they have at least two migraine headaches per month, and that all patients with chronic migraine should receive preventive therapy. But this fails to account for several factors.

For one thing, acute medications are now far more effective than they used to be. "So if I have migraines three times a month, but each one goes away within 20 or 30 minutes with a triptan drug, I don't need to be on migraine prevention," Dr. Rozen noted.

On the other hand, a single migraine each month can leave some patients highly disabled, and those patients are candidates for preventive treatment despite the low frequency of their headaches. The level of disability, and not just the frequency, should guide the decision to use preventive treatment. Of course, preventive treatment should be considered for frequent headaches, especially those that occur two or more times per week.

Prevention also is indicated in conditions such as hemiplegic migraine, migraine with prolonged aura, and basilar migraine, since these carry the risk of permanent neurologic injury.

And prevention should be considered when the patient is overusing acute medications. This is a complicated situation: If the patient is already rebounding, preventive agents won't work, but if the patient is not yet rebounding, preventive treatment will assist the patient in discontinuing the acute medications, Dr. Rozen said.

Once the physician and patient have made the decision to go ahead with a trial of preventive medication, the first thing to remember is "start low and go slow." Migraineurs often respond to low doses, and they tend to be sensitive to the side effects.

On the other hand, he added, a common reason for the failure of prevention is an inadequate dose. …

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