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The case
A 40-year-old woman presented with an eight-year history of migraine headaches. The headaches occurred once or twice per week, but usually responded well to a triptan taken soon after onset. Sometimes the headache returned the next day, necessitating a second dose. Occasionally the headaches did not respond well to the triptan; they caused the patient to miss work about once per month. The patient's headache diary shows that she takes a triptan nine days per month. Her physician suggests a prophylactic medication, given that she is at risk for medication overuse headache and experiencing substantial disability despite taking the medication. The patient's medical history includes asthma that is well controlled. She generally sleeps well and has no history of clinically significant mood disturbance. Physical examination is normal except for obesity. Which prophylactic medication should be tried first?
Migraine headache is a common, disabling condition. The diagnostic criteria for migraine headache1 according to the International Headache Society are shown in Box 1. When migraine episodes are frequent, treatment can be challenging. Prophylactic therapy for migraine remains one of the more difficult aspects. Although valid randomized controlled trials exist to aid decisionmaking, all of the medications used in treatment have incomplete efficacy, and most produce adverse effects.
In this review, we discuss when to consider prophylaxis for the patient with migraine, and provide a systematic review of the evidence available from randomized controlled trials on prophylactic agents. Existing guidelines on this topic are out of date2 or do not include a systematic review of the literature.3
Medications used to treat this condition can be divided into two broad categories: symptomatic or acute-care medications to treat individual migraine episodes, and prophylactic or preventive medications, which are used to reduce headache frequency.
Symptomatic migraine therapy alone, although helpful for many patients, is not adequate treatment for all. Patients who have frequent episodes of migraine may sustain substantial disability despite appropriate symptomatic therapy. When symptomatic medications are used too frequently, they can result in increased frequency of headache and medication overuse headache.1,4 The Canadian Headache Outpatient Registry and Database Project found that 21% of patients with a diagnosis of migraine who were referred to headache specialists had symptomatic medication overuse.5
When prophylaxis should be started is a...