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Prevention Strategies Reviewed for Women With Migraines
The best prevention strategies for women with migraines are reviewed in an article published in the August issue of the Mayo Clinic Proceedings. The authors emphasize specific migraine prevention strategies for each stage of a woman's life.
"The predominance of this disorder in reproductive-age women and its associated social, functional, and economic consequences make migraine management an important issue in women's health," write Beverly S. Tozer, MD, from the Mayo Clinic College of Medicine in Scottsdale, Arizona, and colleagues. "As women progress through the life stages, the hormonal milieu has a substantial effect on migraine. Menstruation, pregnancy, oral contraception, menopause, and hormone therapy influence its incidence and management."
Migraine is common in women, occurring more frequently than diabetes mellitus, osteoarthritis, or asthma, and affecting 27% of women of reproductive age. One-year migraine prevalence is 18% in females vs 6% in males older than 12 years. A thorough understanding of hormonal influences is critical for optimal management of migraine. Although migraine affects many women throughout their life span, only 3% to 5% of them receive preventive therapy.
The US Headache Consortium has specified situations that warrant preventive treatment of patients with migraine. These include recurring migraines that interfere significantly with daily activities despite acute treatment (eg, >/= 2 attacks per month causing disability lasting >/= 3 days); frequent headaches (>/= 2 per week); contraindication to, failure of, or overuse of acute therapies; adverse events, resulting from acute therapies; patient preference for preventive vs abortive therapies; and uncommon migraine conditions that could lead to neurologic damage, including hemiplegic migraine, basilar migraine, migraine with prolonged aura, or migrainous infarction.
The mainstay of preventive treatment should always include nonpharmacologic strategies. Patients should avoid migraine triggers, especially too much or too little sleep, alcohol, caffeine, and fasting or skipping meals. They should follow a healthy lifestyle including good nutrition, regular sleep, and exercise, and they should use nonpharmacologic techniques to reduce migraine, such as relaxation and biofeedback.
Preventive medications should be taken regularly to reduce the frequency, duration, and severity of anticipated attacks; to reduce the need for abortive medication; and to optimize ability to function. Several well-designed trials have confirmed the efficacy of some treatments, and the US Headache Consortium has recommended other treatments in the absence of relevant randomized controlled trials.
These include beta-blockers (propranolol, timolol, atenolol, metoprolol, nadolol); tricyclic antidepressants (amitriptyline, nortriptyline, protriptyline, doxepin); calcium channel blockers (verapamil); selective serotonin reuptake inhibitors (paroxetine, fluoxetine); neuromodulators (divalproex sodium, valproic acid, gabapentin, topiramate); nonsteroidal anti-inflammatory drugs (NSAIDs) mainly for menstrual migraine; and miscellaneous agents (lisinopril, magnesium, vitamin B2, feverfew, and botulinum toxin type A injections).
The authors offer specific strategies for prevention of migraine during menstruation, pregnancy, menopause, late life, and with use of oral contraceptives (OCs).
Miniprophylaxis for menstrual migraine may involve use of naproxen sodium, magnesium, ergotamine tartrate plus caffeine, frovatriptan, naritriptan, or sumatriptan. For long-term prevention, standard preventive medications may be used daily, with increased long-term medication dose perimenstrually if needed. Hormonal manipulation may include extended-cycle use of combined OCs, preferably monophasic, low-dose ethinyl estradiol (EE); or add-back estrogen therapy during the placebo week of combined OCs.
"When selecting preventive therapies, physicians should consider the evidence-based efficacy of the agent, medications used previously, patient preference (eg, weight loss or gain, sedation), cost of the drug, and potential therapeutic opportunities to treat migraine and comorbid conditions with a single drug (eg, hypertension and migraine treated with a β-blocker)," the authors write. "All medications should be initiated at a low dose and increased slowly until the effective or maximum dose is achieved or intolerable adverse effects develop. Each treatment option should be given a full therapeutic trial of 2 to 6 months."
Although at least a 50% reduction in the frequency of headaches may often occur with 4 weeks of treatment, the full effect may not be realized for 3 months. Approximately half of patients do not respond adequately to the initial preventive medication. Diary monitoring of frequency, severity, and duration of migraine attacks during treatment will help evaluate the efficacy of the preventive regimen.
"A combined approach using acute and preventive treatment increases the likelihood of long-term benefit," the authors note. "Preventive treatment may reduce the incidence of and vulnerability to attacks, and acute treatment aids in reducing migraine-related disability during attacks."
An important caveat is not to overuse combination analgesics, opioids, ergot alkaloids, and/or triptans for acute migraine attacks, as these may cause medication overuse headaches. During periods of symptomatic treatment abuse, the benefit of preventive medications can be abolished, but the benefit can be regained when medication abuse is successfully terminated. To avoid overuse of acute treatment, clinicians should strictly limit its use to an average of no more than 9 days per month.
"With a decrease in the need for acute treatment, preventive medications greatly decrease the incidence of medication-overuse headaches," the authors conclude. "Preventive medications can effectively reduce resource utilization by decreasing the use of other migraine medications, the use of diagnostic tests, and visits to physician offices and emergency departments. An understanding of the treatment options available for migraine prevention in women at various life stages can help physicians select appropriate prophylactic therapy."