Probably all of us with migraines dream of a way to prevent our migraines before they occur. There are three broad migraine treatment categories: preventive, abortive and rescue. Dr. Elizabeth Loder, chief of the division of Headache and Pain of the Department of Neurology at Brigham and Women's in Boston and past president of the American Headache Society, said at the Scottsdale Headache Symposium 2014 that preventive treatment of migraine is probably the most important thing that headache and migraine practitioners do in their work as specialists. A show of hands indicated that the majority of specialists agree with this assessment. Dr. Loder stated that the ability to move people to less frequent migraines substantially decreases both the financial cost and the personal impact and misery of migraines on individuals and society.
What are preventive medications and how do you determine if you should be taking one? Preventive medications are taken on a daily basis with the to reduce the frequency and severity of migraines. Preventives should be considered when a person:
- experiences frequent headaches and / or migraines
- fails to respond to acute medications
- experiences contraindications or side effects to acute treatments
- overuses acute medications
- experiences significant difficulty or consequences as a result of his/her migraines
Additionally, Dr. Julie Bryson of the Headache Institute at Mt. Sinai Roosevelt Hospital, who also spoke on preventive treatments at the Scottsdale Headache Symposium 2014, suggested that individuals who have migraines such as hemiplegic migraine that may result in permanent neurological injury if not treated, should consider preventive treatment. Dr. Bryson provided a guideline of two or more migraines a week as being a strong indicator that one would benefit from preventive treatment.
The goal of preventive treatment is to decrease migraine frequency and/or severity by 50%, which is not what many people think of a successful treatment. Dr. Loder discussed a study on "Preventative Pharmacologic Treatments for Episodic Migraine in Adults" by Shamliyan, et al. (2013) in which they found that the average headache and migraine specialist needs to treat 1,000 patients in order to give 200 to 400 of them 50% or greater reduction in migraine and or headache frequency. Her conclusion is that while this is a disappointing statistic, that it is better than nothing.
The goal of 50% reduction in migraine frequency and/or severity can be difficult to assess. Dr. Loder indicated that one of the primary reasons for this difficulty is that migraines that never happen may not be noticed. It's easy for us as migraineurs to be aware of the presence of migraine symptoms and be disappointed that our preventive medication is not working as we would like; however, it may be that our expectation is for the elimination of migraines and that we have failed to keep track of or notice the reduction in severity and frequency of our migraines. It's human nature to notice things that disrupt our life more readily than those which don't, making the awareness of fewer or less severe migraines difficult to track. For this reason, a migraine diary is essential in determining the effectiveness of preventative treatments. It's by tracking change over time that we're able to see if there is any appreciable decrease in the frequency and severity of migraines and if our preventive medication is, in fact, successful.
Another reason preventive migraine treatments are under-valued is that virtually all medications have some kind of side effects. Side effects may range from temporary or minor to permanent or intolerable. Thus, it's important for patients and physicians to consider the cost/benefit of any preventive treatment. For example, in the case of topirimate (Topamax), many individuals experience tingling in their fingers. While this tingling may be uncomfortable, it is not usually indicative of a significant underlying problem. In this case, it must be determined if the decrease in migraine frequency and severity as a result of topiramate outweighs the discomfort and inconvenience of the tingling.
On the other hand, some people have reported frequent kidney stones as a result of topiramate use. In this case, the pain of passing kidney stones or having kidney stone removal surgery may outweigh the benefits of topiramate in preventing migraines. It's also been found that topiramate can, in rare but real cases, cause glaucoma, which is permanent and irreversible. This is something that can only be determined when patients sit down and talk with their doctor about the cost/benefit of the medication and the specific side effects which they are experiencing. Dr. Loder points out that it is important to realize that all preventive medications have side effects and are only partially effective.
If we can only expect limited effectiveness from preventive treatments and are likely to experience side effects from preventive medications, why should they even be used? First of all, partial effectiveness is certainly better than no relief at all. However, there are some other important reasons to consider using preventive medications.
These medications may actually increase the effectiveness of acute treatments, as well as reduce recurrence of migraines. Dr. Loder attributes this to the "kindling theory."
The kindling theory, as defined by Merriam-Webster Dictionary, is "the electrophysiological changes that occur in the brain as a result of repeated intermittent exposure to a sub threshold of electrical or chemical stimulus so that there develops a usually permanent decrease in the threshold of excitability."
This means we may need less medication over time to do the same job.
Therefore, the goal of preventive treatment is to take medication at an optimal level for a while, then if it can be decreased over time so that we are ultimately on the lowest possible dose to maintain the desired level of migraine control. Another goal of preventive medication is to reduce the days missed of work or meaningful life engagement due to migraines. Dr. Bryson also indicated that preventive treatments might reduce what she calls "presentee-ism."
Presentee-ism refers to those situations in which most of our symptoms are controlled, but we are still only partially "there" - not being as fully present and involved as we would like to be. She compared this to being a "zombie who is just getting through the day."
Once we've decided, with our doctor, to try preventive medication, how do we decide which of the many preventive options is best for us? Dr. Loder emphasized that the choice of medication depends on the individual patient, their situation and their concerns. With this in mind, there are seven key factors to consider:
- Accessibility of the medication
- Comorbid medical conditions
- Ease of use
- Tolerability of side effects
Cormobid medical conditions are of particular interest to us as patients. Physicians may select a preventive medication to use the side effects for patient benefit. For example, a patient who experiences depression with their migraines may be given an antidepressant, such as amitriptyline or venlafaxine, to help with both mood and prevention of migraines. A person with high blood pressure may be given a beta-blocker, such as atenolol or propranolol to reduce both blood pressure and migraine frequency or severity. On the other hand, there are times when a patient's comorbid condition rules out the use of a medication. For example, individuals with bleeding disorders may not be given Coenzyme Q10 or NSAIDS (non-steroidal anti-inflammatory drugs) as they can increase bleeding risk. A woman with cardiac issues may not be given a triptan such as naratriptan (Amerge) or zolmitriptan (Zomig) even though they can be used as a short-term, repeated preventive for those with menstrual migraines because of cardiovascular risk.
Selection of preventive migraine treatment is both a science and an art. There is no formula for determining what preventive treatment is right for any particular person. Physicians must use the best scientific evidence of its efficacy and combine that with the needs of the individual patient. Patience is critical when determining the right preventive medication. There will almost inevitably be some trial and error in the process. It's unrealistic to expect to try just one preventive medication. Many of us will find that we'll try one medication for a two or three months before we can decide whether it's successful for us and that we'll then need to try another medication. Others may find that a preventive medication works well at first and over time diminishes in its effectiveness, so another preventive must be tried. For this reason, there are some guidelines most doctors consider when giving a preventive. Dr. Loder identified these treatment principles as:
- Start low and go slow
- Adequate treatment duration and dose
- Choose treatments based on comorbidity and side effects and patient preference rather than just on efficacy
- Quantify treatment effects through the use of a Migraine diary
- Reevaluate treatment at regular intervals
While we all want to reach the maximum benefit we can from a medication as quickly as possible, it's important to titrate (gradually adjusting medication dosage until it reaches the desired effect) medications. Dr. Bryson pointed out that migraine sufferers are often more prone to side effects than non-migraineurs. However, if we slowly increases the amount of medication until the optimal dose is realized, then side effects may be minimized and less intrusive. Additionally, it's important to take any preventive medication long enough to reach a therapeutic dose and to see if the medication can be tolerated while reducing the frequency and severity of migraines. Most preventives should be taken for at least two to three months before we decide to try a different preventive unless there are significant side effects or contraindications to taking the medication that would require stopping the medication sooner. This makes the use of a migraine diary and follow-up appointment essential. While most of us would like to think we're able to accurately report the effectiveness and impact of a medication over time, memory is likely to be inaccurate after a couple of weeks without the use of a detailed migraine diary. Additionally there is the previously mentioned phenomenon that a migraine that never happens may not be noticed. Determining the appropriate preventive medication and dosage is a collaborative process between the patient and the migraine specialist.
There are two other important considerations in selecting a preventive medication. First is the question of whether or not preventive treatment should include a prescribed medication. In fact, there are times when the best preventive treatment is non-pharmacological in nature. Cognitive behavioral treatments, such as relaxation training, biofeedback, and cognitive behavioral therapy, have been found to yield 35 to 55% improvement in migraines. Cognitive behavioral treatments may be of particular use to those who are particularly sensitive to or adverse to side effects. Secondly, one must consider whether or not combination therapy (the use of more than one drug or modality) is appropriate for them. In some cases, the combined use of two medications can be more effective than the use of a single medication. For example, the combined use of a beta-blocker and valproate were found to be more effective in fifty percent of previously resistant cases. However, it should also be noted that of this fifty percent, twenty percent were unable to tolerate the side effects in even low doses.
Similarly, beta blockers and topiramate showed fifty percent reduction in migraines in sixty percent of the individuals who took them together, but again seventeen percent of them had to discontinue this due to side effects. It is important to note, however, that one cannot know if they will experience intolerable side effects unless the medication is tried. Patients need to carefully decide with their doctors, if fear of side effects is reason enough not to try a treatment. In some cases, it may be, and in others it won't. A combined therapy that has been seen to be particularly promising is the combination of behavioral treatment with pharmacological treatment. In this case, studies show a significant change in the number of migraine days per month.
Lastly, many migraineurs ask if they will have to continue to take preventive medications for the rest of their lives. Dr. Bryson noted three key considerations in determining when or if to stop taking a preventive medication.
- Patients need to experience six to twelve months of good migraine control before even thinking about titrating down on a medication.
- Patients need to know that there are good migraine hygiene tools that may aid in staying off of preventive medication. These include regular sleep, normal BMI (body mass index), exercise, proper diet and trigger management.
- Patients, in collaboration with their doctors, need to determine how they feel while on preventive medications versus how they feel once they have titrated off preventive medication. If they experience decreased migraine frequency and severity while on medication as opposed to off medication, they then again must assess the cost-benefit of continuing on a preventive medication and make a decision based on their preference and well-being.
The matter of preventive medications is complicate. All preventive medications are only partially effective, and they all have side effects. There is no one-size-fits-all rule when it comes to preventive medications. This is a very personal decision that can only be made between each of us and our physician. We must be sure that we understand the limitations of preventive medication, the goals of preventive medication, and how to determine if a preventive medication is successful or not. Keeping a thorough migraine diary and working working with our doctors are essential in determining whether or not any preventive medication is right for us. And last but not least, we must be patient. It takes time and collaboration to find the right preventive regimen!
Bryson, Julie. "Preventative Treatments: What to Use and When" Lecture, Scottsdale Headache Symposium from American Headache Society, Scottsdale, November 20, 2014.
Loder, Elizabeth. "Head Talks - Preventative Treatment of Migraines" Lecture, Scottsdale Headache Symposium from American Headache Society, Scottsdale, November 21, 2014.
Wishing you health, hope & happiness,