Migraine Treatment
Most treatments for migraine (acute and preventive) are well-known to treating physicians. Sadly, these were unchanged for decades until recently.
Acute treatment: the current American Headache Society evidence assessment for acute therapy states that all triptans in all formulations as well as dihydroergotamine (nasal spray) have Level A effectiveness. Level A evidence requires at least two Class I studies.23 Ergotamine and other forms of dihydroergotamine are probably effective with Level В evidence. Level В evidence requires one Class I or two Class II studies. Nonspecific medications showing Level A evidence include acetaminophen, nonsteroidal anti-inflammatory drugs (aspirin, diclofenac, ibuprofen, and naproxen), opioids (butorphanol nasal spray), sumatriptan/naproxen, and the combination of acetaminophen/ aspirin/caffeine. Level В evidence has been noted for ketoprofen, intravenous and intramuscular ketorolac, intravenous magnesium (in migraine with aura), isometheptene compounds, codeine/ acetaminophen, and tramadol/acetaminophen. Antiemetics including prochlorperazine, droper- idol, chlorpromazine, and metoclopramide are Level B. There is inadequate evidence for butal- bital and butalbital combination, butorphanol or meperidine injections, intranasal lidocaine, and corticosteroids.23
Preventive treatment: the most recent guidelines for the prevention of episodic migraine by the American Headache Society/American Academy of Neurology, the Canadian Headache Society, and the European Federation of Neurological Societies were published in 2012.24 The medications with Level A evidence included sodium valproate, topiramate, propranolol, timolol, metoprolol, and frovatriptan (prevention of menstrual migraine). There is Level В evidence for amitriptyline, venlafaxine, atenolol, and nadolol as well as naratriptan and zolmitriptan for short-term menstrual migraine prevention. Level C (possibly effective) evidence was noted for lisinopril, candesartan, clonidine, guanfacine carbamazepine, nebivolol, and pindolol. Finally Level U (conflicting or inadequate evidence) was noted for gabapentin, fluoxetine, fluvoxamine, protriptyline, nicardipine, nifedipine, nimodipine, verapamil, and acetazolamide.
New Thoughts on Treatment
With the rise of complementary and alternative medicine worldwide, an increasing number of supplements and vitamins have been suggested as effective migraine treatments. Many of these treatments have shown benefit, leading to varying degrees of endorsement in migraine guidelines for butterbur, feverfew, coenzyme Q10, and others.25 Butterbur, however, has since been associated with rare but severe hepatotoxicity, so the headache societies have suggested to avoid its usage.
Botulinum toxin type A is approved by the Food and Drug Administration (FDA) for use in the preventive treatment of chronic migraine. A recent study using insurance claims data demonstrated that botulinum toxin therapy significantly reduced headache-related emergency department visits and hospitalizations when compared to other oral migraine preventative medications.26 Botulinim toxin is typically reserved for patients who have failed two to three preventative medications and are experiencing chronic migraine per ICHD criteria.1
Non-invasive brain stimulation is a broad term that includes transcutaneous magnetic stimulation (TMS) and transcutaneous direct current stimulation (tDCS). These modalities, which have been studied as both preventative and acute treatments, offer the advantage of being non-medicinal, non-invasive, typically painless, and rapidly administered. There are currently two main commercially available tDCS devices that have been studied in migraine: Cefaly (supraorbital/supra- trochlear stimulation) and gammaCore (external vagal nerve stimulation). Both devices deliver low-dose electric current and have been approved by the FDA for use in migraine. Few data are available from randomized sham-controlled studies to evaluate the efficacy of tDCS devices; however, subgroup analysis from a recent meta-analysis of non-invasive brain stimulation found moderate quality evidence suggesting that tDCS reduced pain intensity, number of migraines, and acute medication intake.27 The Cefaly device has been shown in randomized controlled trials (RCTs) to be of benefit for both abortive and preventative therapy and is FDA-approved for the prevention of episodic migraine. The gammaCore device (a peripheral vagal nerve stimulator) has shown efficacy in randomized controlled trials as an acute treatment for episodic and chronic migraine.28 TMS, which applies magnetic impulse to the cerebral cortex, has shown some benefit for use as an abortive treatment for migraine. The open-label, multicenter ESPOUSE study, published in January 2018, suggested that TMS is safe and effective for the prevention of migraine.29 The previously mentioned systematic review and meta-analysis revealed that non-invasive brain stimulation, including TMS and tDCS, had a low to very low quality of evidence and no clear benefit over sham treatment in a review of studies up to January 2016; open-label studies since that time have been generally positive, so the true benefit of these therapies remains to be seen in clinical practice.
