Migraine headache prophylactic

Prophylactic therapies (Table 53-4) are administered on a daily basis to reduce the frequency, severity, and duration of attacks, as well as to increase responsiveness to acute symptomatic therapies. A treatment algorithm for prophylactic management of migraine headache is shown in Fig. 53-2. 

FIGURE 53-2. Treatment algorithm for prophylactic management of migraine headaches. (NSAID, nonsteroidal antiinflammatory drug.)... 

Dihydroergotamine For the acute treatment of migraine headaches with or without aura and the acute treatment of cluster headache episodes (injection only). Dihydroergotamine nasal spray is not intended for the prophylactic therapy of migraine or for the management of hemiplegic or basilar migraine. 

Propranolol reduces the frequency and intensity of migraine headache. Other 13-receptor antagonists with preventive efficacy include metoprolol and probably also atenolol, timolol, and nadolol. The mechanism is not known. Since sympathetic activity may enhance skeletal muscle tremor, it is not surprising that 13 antagonists have been found to reduce certain tremors (see Chapter 28). The somatic manifestations of anxiety may respond dramatically to low doses of propranolol, particularly when taken prophylactically. For example, benefit has been found in musicians with performance anxiety ("stage fright"). Propranolol may contribute to the symptomatic treatment of alcohol withdrawal in some patients. 

Lysergic acid is a well known component especially as its amide derviative - lysergic acid diethyl amide (LSD) - to be considered in the next section on CNS drugs. Today ergotamine can be used in the treatment of chronic migraine headache although its side effects do not make it an appropriate prophylactic. It is usually compounded with caffeine and administered orally, by inhalation or suppository. The caffeine increases oral and rectal absorption of the ergotamine. Oral dose is 2 mg at onset and 2 mg at 30 minute intervals up to 6 mg with no more than 10 mg administered per week. 

Feverfew is most often used as a prophylactic remedy for migraine headache. This action has been related to the serotonin hypothesis for migraine causation (see also Chapter 16 Histamine, Serotonin, the Ergot Alkaloids). In vitro, feverfew and parthenolide inhibit platelet aggregation and serotonin release from platelets. 

The use of feverfew as a prophylactic remedy for migraine headache is extensively described in the anecdotal literature. Unfortunately, most of the reported formal trials used small samples and had variable outcomes. 

FIGURE 59-3. Treatment algorithm for prophylactic management of migraine headaches. 

As in migraine, therapy for cluster headaches involves both abortive and prophylactic therapy. Abortive therapy is directed at managing the acute attack. Prophylactic therapy is intended to shorten the duration of episodic cluster attacks, in addition to reducing the frequency and severity of attacks in both episodic and chronic cluster headache. Prophylactic therapies are started early in the cluster period and administered daily until the patient is headache-free for at least 2 weeks. The medication is then tapered but may be restarted with the next cluster period. Patients with chronic cluster headache may require prophylactic medications indefinitely. 

Cluster headache responds to many of the same treatment modalities used in acute migraine however, initial prophylactic therapy is required to limit the frequency of recurrent headaches within a periodic series. A novel therapy specific to cluster headaches is the administration of high-flow-rate oxygen 100% at 5 to 10 L/minute by non-rebreather facemask for approximately 15 minutes.42 If pain is not aborted, then retreatment is indicated. No side effects are seen with short-term oxygen use. If oxygen therapy is not wholly effective, then pharmaceuticals... 

Double-blind withdrawal of feverfew leaf from migraine sufferers who were regular users led to a significant increase in the frequency and severity of headaches (see Chapter 30). A prospective, randomized, double-blind, placebo-controlled trial subsequently found that feverfew was an effective prophylactic migraine agent. The sesquiterpene lactone parthenolide is considered to be an important constituent, but other constituents may also play a significant role. 

Cannabis, or marijuana, has been used for centuries for both symptomatic and prophylactic treatment of migraine. It was highly esteemed as a headache remedy by the most prominent physicians of the age between 1874 and 1942, remaining part of the Western pharmacopoeia for this indication even into the mid-20th century. Current ethnobotanical and anecdotal references continue to refer to its efficacy for this malady, and biochemical studies of THC and anandamide have provided a scientific basis for such treatment (Russo, 1998). 

Methysergide, a 5-HT c antagonist, has been used for the prophylactic treatment of migraine and other vascular headache, including Horton s syndrome. Calcium-entry blockers such as flunarizine have been shown to be effective in treating migraine. 

Pharmacology In vitro studies have shown decreased histamine release from mast cells, inhibition of prostaglandin and leukotriene formation, and decreased TNF expression. The fresh leaves of feverfew are thought to have prophylactic value in migraine. Three of five randomized, double-blind, placebo-controlled trials in migraine showed reductions in headache frequency and severity and in nausea. The only well-controlled study of feverfew in rheumatoid arthritis failed to show clinical benefit. 

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