A European Look at the New AAN Migraine Guidelines
Hello, ladies and gentlemen. I am Christoph Diener. I am a neurologist from the Department of Neurology and the Headache Center at the University of Essen in Germany. Today I would like to talk about the new guidelines from the American Academy of Neurology and the American Headache Society on the prophylaxis of migraines. These guidelines were published recently in Neurology.[1]
The guidelines group analyzed all the randomized trials published between 1999 and 2009 and evaluated the outcomes of these studies to devise 5 basic categories of response to treatment. In level A, the medication is definitely working in the prevention of migraine; level B, the medication is probably effective; level C, the medication is possibly effective; level U reflects inadequate or conflicting data, with no possibility to say whether the medication works or not; and finally, the medications are clearly not effective.
Among clearly effective, level A drugs, the authors included the beta-blockers metoprolol, propranolol, and timolol and the antiepileptic drugs valproate sodium, d-valproate sodium, and topiramate. In level B, they found amitriptyline and venlafaxine to be probably effective, along with the beta-blockers atenolol and nadolol. In level C, they found that lisinopril and candesartan, the alpha-agonists clonidine and guanfacine, the antiepileptic drug carbamazepine, [the beta-blockers nebivolol and pindolol], and the antihistaminic drug cyproheptadine were possibly effective. But lamotrigine and clomipramine were clearly not effective for migraine prevention.
The group also evaluated nonsteroidal anti-inflammatory drugs and herbal medicines for this indication[2] and found that petasites (butterbur), which is an herbal remedy, is probably effective. There is some indication that the anti-inflammatory drugs like ibuprofen, ketoprofen, and naproxen could be effective, as can MIG-99 (the CO-2 extract of feverfew), magnesium, and riboflavin. They found that aspirin, indomethacin, and omega-3 acids were not effective.
As a European, I agree with most of these conclusions. However, I strongly disagree about the role of carbamazepine and oxcarbazepine. Carbamazepine is clearly not effective. In Europe, we have flunarizine, a calcium channel blocker that is not available in the United States.
There is an inherent problem in these kinds of meta-analyses and guidelines because they rely on published randomized trials. But as soon as the drug is off patent, no more trials are completed. A typical example is amitriptyline. I strongly believe that amitriptyline is effective for preventing migraine, and we have 35 years of experience with this drug. Unfortunately, it has been put in the same class of evidence as venlafaxine, for which we have only 1 properly conducted randomized trial.
In my daily practice, I usually start with a beta-blocker if there are no contraindications; if it is not tolerated or found ineffective, I switch to topiramate. I prefer topiramate over valproic acid because [the latter] leads to weight gain, and topiramate is less dangerous for women of childbearing age.
Ladies and gentlemen, this is a very worthwhile publication to read, and I agree that the prevention of migraines should be evidence-based. Dear colleagues, I am Christoph Diener, a headache neurologist from Essen, Germany. Thank you for listening.
Medscape Neurology © 2012 WebMD, LLC
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