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Undertreating Migraines Increases Frequency of Attacks

migraine headaches, American Academy of Neurology

The National Headache Foundation estimates that 28 million Americans suffer from migraines. Women tend to suffer more than men with a quarter of all women with migraines having four or more attacks a month. Drugs are the first-line treatment, but many are concerned that taking too much can lead to rebound headaches. The American Academy of Neurology (AAN) and the American Headache Society though find that undertreating a migraine may also increase frequency of attacks.

The AAN has released new guidelines at their 64th Annual meeting in New Orleans this past month. The evidence-based update reviews migraine prevention, as well as over-the-counter and complementary treatments, based on results from 29 Class I or Class II studies published between June 1999 and May 2009.

The guidelines state that 38% of migraine sufferers require preventive therapy, but just three to 13% currently use it. With preventive treatments, says Mark Green MD, director of the Headache Center at Mount Sinai School of Medicine, headaches could be reduced by as much as 50%. Plus, “if we allow migraines to progress, the frequency of attacks may increase, and they may also become harder to treat,” he warns.

Prescription drugs with the strongest evidence for prevention must be taken every day to prevent migraine attacks and reduce the severity of attacks. The anti-seizure medications divalproex sodium, sodium valproate, and topiramate, as well as beta blockers metoprolol, propranol, and tumolol, are effective for migraine prevention. However, the antiseizure drug lamotrigine is not effective in preventing migraine, and should not be used.

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Unfortunately, patients who suffer from migraines may also take OTC or alternative treatments that are not effective. Those that do show promising results include the herbal preparation Petasites (butterbur) and NSAIDS such as fenoprofen, ibuprofen, ketoprofen, naproxen, and subcutaneous histamine. Other complementary treatments that are “probably effective” include magnesium, MIG-99 (feverfew) and riboflavin.

Although these OTC or alternative treatments do not require a prescription, patients should still see a doctor if they are considering these for migraine prevention, says guideline author Stephen D. Silberstein, MD, FACP, FAHS, of Jefferson Headache Center at Thomas Jefferson University in Philadelphia and a Fellow of the American Academy of Neurology.

“Migraines can get better or worse over time, and people should discuss these changes in the pattern of attacks with their doctors and see whether they need to adjust their dose or even stop their medication or switch to a different medication,” he says. “In addition, people need to keep in mind that all drugs, including over-the-counter drugs and complementary treatments, can have side effects or interact with other medications, which should be monitored.”

In addition to monitoring the effectiveness of any prescription or non-prescription medication, patients should also try to determine which triggers are most likely to set off a migraine. To determine what may be effecting you (every patient is different), keep a headache journal which includes information such as foods eaten (common triggers are processed, fermented, pickled or marinated foods, MSG, foods containing tyramine, and nitrates) and stresses that cause anxiety or changes in sleep habits.

Journal Reference:
SD Silberstein, S. Holland, F. Freitag, et al. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012;78;1337. 10.1212/WNL.0b013e3182535d20



Preventive treatment did NOTHING for me - it was only adequate abortive therapy when I got them that kept them to about 3-4 times a year. W/O that they are weekly, and multiple days in a row - and the triptans make them worse. Sleep therapy is the ONLY thing that works and nobody seems to want to use that any more. Various heart medications and antidepressants were worse than useless as there were other side effects (and I'm not sure those aren't permanent). What's worse is that certain tv shows have portrayed migraineurs as drug seeking addicts. My wish is that all doctors who undertreat migraines go through a 4 day one and see if they'd undertreat one again.