Part 2 discusses the role of preventative prophylactic pharmacotherapy and the role of migraine treatments in special populations. It also provides an overview and guideline summary for general treatment pathways for the pharmacotherapy of migraine.
Preventative migraine therapy refers to the daily administration of drug therapy for various periods, usually three to 12 months. The goals are to reduce the frequency and severity of attacks, to improve and reduce disability, and to minimize or eliminate the need for abortive drug therapy.
Patients may be candidates for preventative therapy if they are experiencing two or more migraines per week, if their attacks last more than 48 hours, or if they have ineffective responses or contraindications to abortive therapy. Adapted from references 124and Beta blockers were first recognized in the s as effective in migraine prophylaxis; by the s, their use was well established, and they continue to be a treatment of choice. Studies with other beta blockers, including some nonselective agents e.
Beta-1 selective agents may be an appropriate option in patients with severe respiratory disease, 23 — 26 but singulair and migraine management with intrinsic sympathomimetic activity should be avoided because of a lack of reported efficacy.
Important interactions involve other cardiovascular drugs that influence heart rate or blood pressure, including numerous antihypertensive agents, singulair and migraine management. The concurrent use of these triptans with propranolol should be monitored carefully.
Lower doses of these triptans should be used, or they should be avoided in favor of an alternative agent. Beta blockers are considered a drug of choice for migraine prevention, especially in patients without absolute contraindications.
They offer an excellent choice for patients with other morbidities, including vitamin c and chemotherapy and coronary artery disease.
Beta blockers should be initiated at low doses along with monitoring of heart rate and blood pressure. An adequate trial of 3 to 12 months with continued assessment of efficacy and tolerability is recommended. Although various classes of antidepressants have been studied and used to prevent migraine headache, prozac and public data are available for the tricyclic antidepressants TCAs Table 1.
The side-effect profile of the TCAs includes dry mouth, constipation, urinary retention, singulair and migraine management weight gain along with central effects sedation, weakness, fatigue, and tremorwhich may limit their use in some patients.
The secondary-amine TCAs nortriptyline Pamelor, singulair and migraine management, Mallinckrodt and desipramine Norpramin, Sanofi-Aventis may be better tolerated in some patients and may be an additional option. More serious adverse effects include potential cardiac events, such as sinus tachycardia, corrected QT QTc prolongation, and blood pressure fluctuations. Drug interactions involve other central-acting agents, anti-cholinergic drugs, and serotonergic agents Table 2.
These medications are contraindicated for patients with angle-closure glaucoma, urinary retention, and orthostatic hypotension, which are seen primarily in the elderly. Monitoring in young migraine patients should include efficacy and adverse effects such as weight gain.
Adapted from references 49 — Within the antidepressant class, the TCAs are considered a first-line option for preventing migraine in patients who do not have any contraindications.
These agents may be an excellent choice for patients with a concurrent comorbidity such as depression, anxiety, or insomnia, singulair and migraine management.
The selective serotonin reuptake inhibitors SSRIs have not shown consistent benefits in migraine prophylaxis. A few small, short-term trials with fluoxetine Prozac, Eli Lilly reported benefits, 4647 although a more recent analysis that looked at the class as a whole reported a lack of efficacy in migraine.
The anticonvulsants are another class of medications that have demonstrated efficacy in the prophylaxis of migraine, with valproic acid and topiramate having the strongest evidence to support this indication see Table 1. Valproic acid and singulair and migraine management derivatives were the first class of anticonvulsants approved for migraine prophylaxis.
Trials dating back to the s have been conducted with efficacy reported at singulair and migraine management doses but without a consistent correlation between effective dose and serum levels. Efficacy was described as a reduction in the severity and duration of migraine, with good tolerability reported with titration and individualized doses see Table 1. Adverse events associated with valproic acid, including central nervous system CNS effects e. More serious adverse events e.
Valproic acid and its derivatives should be avoided in women who sulfasalazine and alergies planning pregnancy or in women of childbearing age because of the significant risk of teratogenicity with this agent. Drug interactions include other central-acting agents and drugs whose metabolism may be inhibited by herbals for anti-aging acid.
The other anticonvulsant that has been studied extensively and has reported efficacy in migraine prophylaxis is topiramate Topamax see Table 1. Although serious adverse effects kidney stones, myopia with angle-closure glaucoma, sedation, singulair and migraine management, and cognitive changes can occur, 444579 clinical trials reported good tolerability in most patients, especially with lower daily doses.
In comparison trials, topiramate was similar to valproic acid 80singulair and migraine management, 81 and propranolol 32 in terms of efficacy and tolerability. Because of concerns about potential dose-related effects on cognition, patients who are taking topiramate must be monitored regularly, although the drug has excellent clinical utility and can be an option, especially if weight gain is a concern. Valproic acid and topiramate provide an additional option in the prophylactic treatment of migraine headaches, but adverse effects may limit their use in some patients.
Small trials with additional anticonvulsant agents singulair and migraine management some benefit with gabapentin Neurontin, Pfizer and levetiracetam Keppra, UCB Pharmainconsistent findings with zonisamide Zonegran, Eisaiand a lack of efficacy with lamotrigine Lamictal, GlaxoSmithKline. Before these agents can be recommended for migraine prophylaxis, additional studies are needed.
Other agents have also been used to prevent migraine; however, many of these therapies are less effective than those discussed earlier, or they need further study.
Calcium-channel blockers have had mixed success in migraine prevention, 90 — 94 with a few small trials suggesting modest benefits with verapamil e.
Although primarily used in the abortive management of migraine, the nonsteroidal anti-inflammatory agents NSAIDs have also demonstrated modest benefits in migraine prophylaxis. Trials with naproxen Naprosyn, Rochefenoprofen Nalfon, Pedinoltolfenamic acid e. Skeletal muscle relaxants, including baclofen e. One controlled trial and an open-label trial with tizanidine reported reduced headache frequency, duration, and intensity.
Although more trials are needed, the angiotensin-converting enzyme ACE —inhibitors and the angiotensin II receptor blockers ARBs have been effective for migraine prevention and may have a future role, especially in patients with cardiovascular comorbidities. The leukotriene receptor antagonist montelukast Singulair, Merck was studied in migraine prevention with mixed results, suggesting that more trials may be needed to clarify its role. One of the more recent products to be studied in migraine prevention is botulinum toxin type A.
Although numerous trials have been conducted, inconsistent findings have been reported, perhaps because of variable trial designs, treatment regimens, or the types of patients studied. Agents that might also be beneficial for migraine prophylaxis include antihistamines, salmon calcitonin Miacalcin, Novartis, simvastatin Zocor, Merck and clonidine Catapres, Boehringer Ingelheim. Various combinations of prophylactic agents have been used in patients who have not responded to monotherapy.
The importance of careful and slow titration of additive agents is essential because of additive side effects, singulair and migraine management, potential toxicities, and drug interactions. The link between female sex hormones and migraine has been studied extensively. This type of migraine appears to be associated with fluctuations in estrogen levels and the resultant biochemical effects of increased prostaglandins, enhanced prolactin release, and other physiological dysregulation.
Treatment has included a variety of agents, including hormonal manipulation and other therapies administered in conjunction with the menstrual cycle.
Migraine headaches usually improve during pregnancy, but treatment may be required in some patients. Simple analgesics like acetaminophen alone are the drugs of choice.
Other therapies can be used with caution and in consideration of the risk—benefit ratio, singulair and migraine management. Although more controlled trials are needed for evidence-based treatment of migraine in children and adolescents, the American Academy of Neurology offers some guidance. Options for abortive treatments are simple analgesics alone or triptans.
The triptans, including sumatriptan Singulair and migraine management, GlaxoSmithKlinerizatriptan Maxalt, Merckand zolmitriptan Zomig, AstraZenecasingulair and migraine management, were reported to be safe but not superior to placebo.
Fewer data are available for prophylactic treatment in children, singulair and migraine management, although several agents have been proposed. New-onset headache in the elderly is considered a secondary disorder, singulair and migraine management, and a comprehensive evaluation is warranted. As with pediatric patients, the safest agent for the abortive management in older adults is acetaminophen, and the use of the ergots and triptans may be limited if patients have cardiovascular or cerebrovascular disease.
The selection of preventative therapies can be determined by concurrent co-morbidities or contraindications. As the choices for the pharmacotherapy of migraine expand, clinicians have multiple options to use for both abortive and preventative management. Various guidelines, including those of the U. Headache Consortium, 4 have recently been revised, although updates are not yet in print.
The available guidelines support the utility of the various pharmacological agents in migraine using a stepped-care approach, singulair and migraine management simple analgesics or NSAIDs as singulair and migraine management choices and stepping up to specific migraine therapies if the response is not sufficient.
With the stratified-care approach, treatment choices are based on the severity shed and barn plans the headache.
The Disability in Strategies of Care DISC Study provided evidence that using a stratified-care approach might be able to improve headache response and disability time. In this multi-center study, which was conducted in 13 countries, the Migraine Disability Assessment Scale MIDAS was used to compare the stratified-care and stepped-care approaches.
For the singulair and migraine management group, initial attacks were treated with aspirin and metoclopramide; patients could use a stepped-care strategy singulair and migraine management an attack and zolmitriptan therapy with set parameters. Investigators conducting future trials of stratification might consider other factors, such as symptom profiles, genetics, and biological markers. Considerations for preventive therapy are usually based on the frequency and severity of migraine and other comorbidities, and these approaches may include beta blockers, TCAs, and anticonvulsants.
The pharmacotherapy of migraine is complex. The appropriate use of preventative medications requires singulair and migraine management understanding of the various agents available and when they are best used. The management of migraine requires a multidisciplinary approach and calls for physicians experienced in headache management along with nurses, social workers, and pharmacists. The large number of patients experiencing migraine results in significant medication usage and the potential for drug-related problems.
Pharmacists should also play a prominent part in educating patients about their medications and in providing information on appropriate use. DeMaagd has no relationships to disclose. This article contains discussions of off-label use. National Center for Biotechnology InformationU. Journal List P T v. Accepted Apr This article has been cited by other articles in PMC.
Prophylactic Therapy Preventative singulair and migraine management therapy refers to the daily administration of drug therapy for various periods, usually three to 12 months. Nadolol Corgard 20— mg q. Atenolol Tenormin 25— mg q. Metoprolol Toprol 50— mg b.
Side effects Heart rate. Open in a separate window. Beta-Adrenergic Blockers Beta blockers were zocor pros and cons recognized in the singulair and migraine management as effective in anti prozac rant prophylaxis; by the s, singulair and migraine management, their use was well established, and they continue to be a treatment of choice.
Antidepressants Tricyclic Agents Although various classes of antidepressants have been studied and used to prevent migraine headache, more data are available for the tricyclic antidepressants TCAs Table 1. Other Antidepressants The selective serotonin reuptake inhibitors SSRIs have los angeles bicycle plan shown consistent benefits in migraine prophylaxis.