Most people who suffer regularly from debilitating migraine headaches don’t get the appropriate treatment to prevent them, according to new guidelines issued earlier this week from the American Academy of Neurology. And a disappointing study published Tuesday in the Journal of the American Medical Association found that injections of Botulinum toxin A, or Botox, had smaller-than-expected benefits for those with chronic, near-daily headaches, working only modestly better than a placebo.
“There are several reasons why patients aren’t being properly treated,” said Dr. Stephen Silberstein, a neurologist at Thomas Jefferson University in Philadelphia who led the guideline committee. “They may be misdiagnosed with tension or sinus headaches or may be using a medication that doesn’t work or is prescribed at too low a dose.”
(Five of the six guideline authors, including Silberstein, disclosed that they had previously served on advisory boards or accepted honoraria or consulting fees from manufacturers of drugs used to treat migraines.)
Migraines -- which are frequently accompanied by nausea, vomiting, visual disturbances or aura, and sensitivity to light -- affect about 1 in 10 Americans and can be triggered by certain foods, lack of sleep, stress, jet lag, fasting, and hormonal changes during a woman’s menstrual cycle. Nearly 40 percent of migraine sufferers have at least four or five headaches a month, and a smaller percentage have “chronic migraines” defined as having pain at least 15 days a month. Women are also more likely to get them than men.
Doctors -- especially primary care physicians who treat most headaches -- may still have the mindset of prescribing drugs to treat headaches after they set in, rather than for prevention, according to Silberstein.
“There may also be reluctance on the part of patients to take medicines every day when migraines come on episodically,” said Dr. Elizabeth Loder, an internist in the neurology department at Brigham and Women’s Hospital and president-elect of the American Headache Society, which endorsed the guidelines. “But the data show that if you have a frequent number of headaches every month, treating them individually can backfire.”
Certain medications to relieve migraine pain can become less effective when used too often or could cause rebound headaches caused by withdrawal from the drugs. The triptan class of drugs -- such as sumatriptan (Imitrex) and frovatriptan (Frova) -- are the most commonly used drugs to treat pain once a migraine sets in, but the guidelines state that they should be used only occasionally for prevention, say, to avert a monthly menstrual migraine or one likely to occur from a planned religious fast.
Low doses of established drugs like anti-seizure medications (divalproex sodium, sodium valproate and topiramate) or anti-hypertensive beta blockers (metroprolol, proprandolol, and timolol) have been shown to be most effective at reducing the number and severity of migraines. In one study, topiramate reduced frequency from an average of six migraines per month to an average of less than two per month.
In a separate guideline, the same panel of experts labeled the herbal remedy petasites -- a plant from the daisy family -- to be an effective preventive treatment on par with anti-seizure medications and beta blockers.
The experts also concluded that antidepressants venlafaxine (Effexor) and amitriptyline are somewhat less effective, according to the latest evidence, but could be a good option if other drugs fail to work. Same, too, for over-the-counter painkillers such as ibuprofen and naproxen sodium -- though, long-term use of those could lead to ulcers and gastrointestinal bleeding.
“There’s no way to predict which medication will work,” said Silberstein. “Patients need to realize that if they fail one drug, there’s just as good a chance that they will do well on a second or third drug. It’s just like going out on a blind date; if you don’t hit it off, you have to keep meeting people.”
His rule of thumb: Try a new medication, at the full recommended dose, for at least a month to see if you get any symptom relief. If not, talk to your doctor about getting a different prescription.
Loder said she hasn’t written off Botox as a second or third line of therapy in those with frequent migraines occurring every day or two. “It can have a small modest benefit, reducing headaches by two or three a month on average, but some have a bigger reduction than others.”