Page 229 Guide to Pain Management in Low-Resource Settings

Headache 217

personal experience, by the local pharmacoeconomic subject to controlled studies, and some, like butterbur
situation, as well as by the available literature. (Petasites), were found clearly more eff ective than pla-
cebo. Several nondrug therapies (such as biofeedback
What prophylactic therapy and psychologically based interventions) have proven
is available in migraine? effi cacy in migraine prophylaxis.

Prophylactic antimigraine treatment must be individ- How is the pharmacological
ually tailored to each patient, taking into account the
prophylaxis therapy in
migraine subtype, the ensuing disability, the patient’s
history and demands, and the associated disorders. A migraine selected?
prophylactic treatment is also useful to prevent the
Interestingly, the recommendations for prophylac-
transformation of episodic migraine into chronic dai-
tic treatment of migraine diff er around the world.
ly headache with analgesic overuse (medication over-
Beta-blockers and valproate are usually among the
use headache).
fi rst choices. Th e choice of drug should neverthe-
A major drawback of most classical prophylac-
less be individualized according to the drug’s side-ef-
tics (beta-blockers devoid of intrinsic sympathomimetic
fect profi le. For example, older patients might benefi t
2+
activity, valproic acid, Ca antagonists, antiserotonin-
from the antihypertensive properties of beta-blockers,
ergics, and tricyclics), which have all on average a 50%
while younger ones may suff er considerably from beta-
effi cacy score, is the occurrence of side eff ects. If the
blocker-induced sedation.
initial trial is successful in reducing frequency of attacks
Apart from the drugs in the list, there are other
without causing signifi cant chronic side eff ects, then
pharmacological options with weaker evidence, including
the preventive therapy may be continued for 6 months.
magnesium (24 mmol daily, especially for migraine asso-
After 6 months, the dose is gradually decreased before
ciated with the menstrual period), Petasites (butterbur),
stopping the treatment. If the treatment is not success-
Tanacetum parthenium (feverfew), candesartan (16 mg
ful, dosing of the medication should be increased up to
daily), coenzyme Q (100 mg t.i.d.) and ribofl avin (400
the maximum allowed, or a new preventive treatment 10
mg daily).
should be initiated.
In recent years, some new prophylactics with
less side eff ects have been studied. Well-tolerated, but Table 5
Selection criteria for prophylactic pharmacological treatment in
poorly eff ective in comparison to the classical prophylac- migraine
tics, are high-dose magnesium or cyclandelate. A novel Drug and Dose Selected Adverse Eff ects
preventive treatment for migraine is high-dose (400 Valproic acid, 500–1000 Liver toxicity, sedation, nausea,
mg/d) ribofl avin, which has an excellent effi cacy/side- mg nightly (sustained weight gain, tremor, teratogenic-
eff ect ratio and probably acts by improving the mito- release) ity, possible drug toxicity, hair loss,
drowsiness
chondrial phosphorylation potential. Coenzyme Q (100
10 Beta-blockers Reduced energy, tiredness, postural
t.i.d.), another actor in the mitochondrial respiratory Propranolol, 40–240 mg symptoms, contraindicated in asthma
chain, is also eff ective in migraine prophylaxis. Lisinopril Bisoprolol, 2.5–10 mg
(10 mg b.i.d.), an inhibitor of angiotensin-converting en- Metoprolol, 50–200 mg
zyme, and even more so, candesartan (16 mg b.i.d.), an Flunarizine, 5–10 mg daily Drowsiness, weight gain, depression,
parkinsonism
angiotensin II inhibitor, well-known for the treatment of
Topiramate, 25–100 mg Paresthesias, fatigue, nausea, cogni-
hypertension, were found useful in migraine. twice daily tive dysfunction
Recent preliminary but encouraging results Amitriptyline, 25–75 mg Weight gain, dry mouth, sedation,
with novel antiepileptic compounds such as gabapentin nightly drowsiness
need to be confi rmed in large randomized controlled Methysergide, 1–4 mg daily Drowsiness, leg cramps, hair loss, ret-
trials, whereas topiramate was found eff ective in several roperitoneal fi brosis (1-month drug
“holiday” required every 6 months)
placebo-controlled trials. Lamotrigine is up to now the
Gabapentin, 900–3600 mg Dizziness, sedation
only preventive drug that has been shown eff ective for daily
migraine auras, but not for migraine without aura. Non- Lisinopril, 10–20 mg daily Cough
pharmacological and herbal treatments are increasingly