Migraine prophylaxis considerations An educational update for providers

The American Academy of Family Physicians and the American College of Physicians-American Society of Internal Medicine have developed clinical guidelines on the pharmacologic management of acute attacks of migraine and prevention of migraine headache.¹ In terms of prevention, the clinical guideline recommends that the following types of patients be evaluated for use of preventative therapy:

• Two or more migraine attacks per month, with the attacks producing disability for 3 or more days per month;

• Use of rescue medication more than twice a week;

• Failure of acute treatments or contraindications for such treatments; or

• The presence of uncommon migraine conditions (e.g., prolonged aura, migrainous infarction, hemiplegic migraine).

In addition, the guideline states that other factors that need to be considered include the patient's preference, adverse events with treatments for acute migraine attacks, and how much treatment costs for acute attacks and migraine prevention.¹

The American Academy of Neurology (AAN) has also published evidence-based guidelines for management of migraine headache ² Within this document the AAN recommends that use of preventative therapies can be considered for the following reasons:

• Recurring migraines that, in the patients' opinion, significantly interfere with their daily routine

• Frequent headaches

• Contraindication to or failure or overuse of acute therapies

• Adverse events with acute therapies

• Cost of both acute and preventative therapies

• Patient preference

• Presence of uncommon migraine conditions

The AAN guidelines do not quantify the number of migraine attacks or the amount of acute treatments used before preventative therapy should be considered.² They note that the goals of preventative treatment are to reduce the frequency, severity, and duration of attacks; improve responsiveness to treatment of acute attacks; and improve overall patient function and reduce disability.

The AAN evidence-based guideline also discusses treatment recommendations for acute attacks. ² They note that triptans are effective and safe for the acute management of a migraine attack and that ANY triptan is a reasonable choice when the headache is moderate to severe. In addition, use of ANY triptan is also recommended to be used in any type of migraine (i.e., does not need to be moderate or severe in nature) when nonspecific medications have failed to provide relief. Intranasal and subcutaneous formulations of sumatriptan are recommended for those with nausea and vomiting.

1. Snow V, Weiss K, Wall EM, Mottur-Pilson C; American Academy of Family Physicians; American College of Physicians-American Society of Internal Medicine. Pharmacologic management of acute attacks of migraine and prevention of migraine headache. Ann Intern Med. 2002;137(10):840-849.
2. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55(6):754-762.

Approved 1/16/13 by the Illinois Drug Utilization Review Board.