October 1, 2009 — Oral non-steroidal anti-inflammatory drugs and triptans, preceded by antiemetics such as metoclopramide or domperidone, are now advised for the acute treatment of migraine under updated treatment guidelines just published by a task force of the European Federation of Neurological Societies.
Dr. Stefan Evers of the University of Munster, Germany, and colleagues reported the guidelines in the September issue of the European Journal of Neurology.
Evers told Reuters Health by e-mail that in addition to the recommendation noted above, the guidelines, last revised in 2006, include only relatively minor changes:
--Zolmitriptan tablet and nasal spray and rizatriptan tablets were determined to be effective in children and adolescents.
--Topiramate is recommended for prophylactic treatment of chronic migraine.
--Botulinum toxin A is not considered effective in episodic migraine.
He noted that in contrast to common practice in the United States, in Europe, typically "antidepressants are not recommended as first choice in the prophylaxis of migraine."
Dr. Stephen D. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, Philadelphia, defended the use of antidepressants for migraine, telling Reuters Health by phone that "Evidence for the tricyclic antidepressants is quite good."
He also said that this difference in the European and U.S. approaches to treatment rests partly on differing definitions of what constitutes migraine. Silberstein said that he hopes to one day see a unified, worldwide set of guidelines for drug treatment of migraine.
The new guidelines were developed through a review of the relevant literature in English, French or German as of the end of 2008. Task force members had to agree unanimously on all recommendations.
Although doctors often give antiemetics before analgesics, to prevent vomiting and increase resorption, the report noted that no prospective, randomized, placebo-controlled studies have yet proved that this practice accomplishes its goal. The authors added that there is no evidence that combining an antiemetic with an analgesic increases the analgesic's effectiveness.
For very severe migraine attacks, the guidelines recommend intravenous acetylsalicylic acid or subcutaneous sumatriptan as the drugs of first choice. Status migrainosus, in which migraine lasts almost without interruption for more than 72 hours, "can be treated by corticosteroids, although this is not universally held to be helpful, or dihydroergotamine," according to the recommendations.
For migraine prophylaxis, beta-blockers (propranolol and metoprolol), flunarizine, valproic acid, and topiramate are the drugs of first choice.
The guidelines also include recommendations for specific situations, such as emergencies, menstrual migraines, migraine in pregnancy, and migraine in children and adolescents.
Eur J Neurol. 2009;16:968-981.
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