Neurology guidelines rate migraine prophylaxis options

Prescription, over-the-counter and complementary treatments for migraine prevention were evaluated in two new guideline updates from the American Academy of Neurology (AAN).

The group's evidence-based update on pharmacologic treatment included 29 article reviews (out of 284 abstracts that were considered) and divides medications into Levels A, B, C and U. According to a Level A recommendation, medications that are established as effective and should be offered for migraine prevention are divalproex sodium, sodium valproate, topiramate, metoprolol, propranolol, timolol and, for menstrual migraines, frovatriptan. In a negative Level A recommendation, the update said lamotrigine should not be prescribed for migraine prophylaxis.

Level B drugs, which are probably effective and should be considered, include amitriptyline, venlafaxine, atenolol, nadolol, naratriptan and, for menstrual migraine, zolmitriptan. Level C options (possibly effective, may be considered) are lisinopril, candesartan, clonidine, guanfacine, carbamazepine, nebivolol and pindolol.

The other update, which covers nonsteroidal anti-inflammatories and other complementary treatments, included 15 article reviews. Petasites (or butterbur) is the only treatment that received a Level A recommendation. Level B options are fenoprofen, ibuprofen, ketoprofen, naproxen, naproxen sodium, MIG-99 (feverfew), magnesium, riboflavin and subcutaneous histamine. Level C treatments are cyproheptadine, Co-Q10, estrogen, mefenamic acid and flurbiprofen. In a negative Level B recommendation, the update said that montelukast was probably ineffective for migraine prevention.

Level U (evidence conflicting or inadequate) treatments (from both updates) include gabapentin, fluoxetine, fluvoxamine, protriptyline, acenocoumarol, warfarin, picotamide, bisoprolol, nicardipine, nifedipine, nimodipine, verapamil, acetazolamide, cyclandelate, aspirin, indomethacin, omega-3 and hyperbaric oxygen. Both sets of guidelines were published by Neurology on April 24.

Also last week, a meta-analysis of botulinum toxin A for prophylaxis of migraine and tension headaches was published in the Journal of the American Medical Association. According to the analysis, the toxin did not reduce the number of episodic migraines or tension headaches per month but provided a small to modest benefit in chronic daily headaches and chronic migraines. The AAN update noted that a new guideline on botulinum toxin is currently in development and that the academy's 2008 guideline contained a Level B recommendation against using the toxin for treatment of episodic migraine.