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Migraine treatment guidelines and treatment recomendations


The American Headache Society (AHS) released a list of commonly treatments or tests for migraine and headache that are not always needed. The list comes about as part of the Choosing Wisely® initiative of the ABIM Foundation. It aims to target five areas, supported by evidence with an effort to support conversations between doctors and patients about what is really needed or necessary. This will be published in Nov-Dec 2013 journal of Headache.

American Headache Society Releases List of Commonly Used Tests and Treatments to Question
“All of us on the front lines of medicine know we have the opportunity to improve the care we deliver by engaging our patients in conversations about what care is really necessary and beneficial to their health. The recommendations in migraine and headache treatment released today provide valuable information to help patients and physicians start important conversations about treatment options and make wise choices,” said Elizabeth Loder, MD, MPH, President of the American Headache Society. Dr. Loder is Chief of the Division of Headache and Pain in the Department of Neurology at the Brigham and Women’s Hospital in Boston.
AHS’s list identified the following five recommendations:
• Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for migraine
• Don’t perform computed tomography (CT) imaging for headache when magnetic resonance imaging (MRI) is available, except in emergency settings
• Don’t recommend surgical deactivation of migraine trigger points outside of a clinical trial
• Don’t prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders
• Don’t recommend prolonged or frequent use of over-the-counter (OTC) pain medications for headache

 This Neurology Now article gets right into the treatments that have been looked into and recommended for migraines... Heading Off Migraine: What's the evidence for non-pharmaceutical approaches? and is well worth reading if you are looking for some ideas.

I know we often think...

But it is always about more than the medication when it comes to chronic migraines...

In a new guideline on migraine prevention issued in April, the American Academy of Neurology (AAN) reported that the following prescription medications have been shown to be effective for preventing migraine by a high level of evidence: the antiepileptic drugs divalproex sodium (Depakote), sodium valproate (Epilim), and topiramate (Topamax); the beta-blockers metoprolol (Lopressor, Toprol), propranolol (Inderal), and timolol (Istalol); and the triptan frovatriptan (Frova). (See “New Migraine Guidelines from the American Academy of Neurology,” page 15, for more on the levels of evidence supporting these therapies, and go to aan.com/guidelines to access the full guidelines.)

Drugs that have been shown probably to be effective in preventing migraine according to the new guideline include the antidepressants amitriptyline (Elavil) and venlafaxine (Effexor), the beta-blockers atenolol (Senormin, Tenormin) and nadolol (Corgard), and the triptans naratriptan (Amerge) and zolmitriptan (Zomig).

On the other hand, strong evidence suggests that the antiepileptic drug lamotrigine (Lamictal) is not effective in preventing migraine, the new guideline states.
 So there are the go to medications. Or not go to medication for Lamictal I guess. There are two that I have not tried, and can try... so gives me some suggestions anyway. I bet they both cause weight gain and zombie brain.

Biofeedback vs Acupuncture


BIOFEEDBACK
“Biofeedback helps someone achieve a calm inner state, diminishing the excitation of nerve cells,” explains Dr. Klein. “People can try to achieve this with meditation as well, but biofeedback offers input so that they know if they are doing it correctly.”
Biofeedback equipment allows people to monitor their automatic bodily responses, especially reactions to stress. The idea is that once the patient learns to monitor these responses, he or she can modify them, changing skin temperature and heart rate, for example.
Two kinds of biofeedback are commonly used to combat migraine: skin temperature biofeedback, which teaches people to warm their hands; and electromyogram (EMG) biofeedback, which teaches people to relax their muscles.
Why would these therapies help with migraines? The idea is that during migraines, blood flow increases to certain areas in the head and decreases in the extremities, such as the hands. Modifying a response such as the temperature of the hands might increase blood flow back to that area, reducing the pressure of blood flow to stressed or overexcited areas in the head. It might also have an overall calming effect on the central nervous system.
“A substantial body of evidence shows that biofeedback improves migraine, and the difference is almost as great as what you see with some prescription drugs,” says Dr. Lipton.

ACUPUNCTURE
Metzger recently started seeing an acupuncturist at the recommendation of a friend, who claims the same acupuncturist rid her of the migraines that had become unbearable since the birth of her second son.
But research findings are less than conclusive.
In two large studies of acupuncture as a preventive treatment for migraine, migraineurs who were assigned to receive “real” acupuncture, in which the needles were inserted along the meridians (key acupuncture regions according to traditional Chinese medicine), did in fact see a reduction in the frequency of their headaches. But so did patients who received “sham” acupuncture—that is, needles inserted at random sites rather than along the meridians.
“One possible conclusion we could draw from these trials is that acupuncture doesn't work,” says Dr. Lipton. “That's the conventional view: that these are failed studies. Another possibility is that placing the acupuncture needles just about anywhere is an effective treatment for migraine, not just along the meridians.”
Dr. Lipton doesn't suggest that his patients try acupuncture, but he is happy to refer if a patient asks. “My clinical experience is that a lot of patients do better when they get acupuncture,” he says.

And the vitamins and supplements? How do they fair in the recommendations?

Of them all... "BUTTERBUR EXTRACT According to the new AAN guideline, the only supplement shown to be effective in preventing migraine by a high level of evidence is extract of the root of the butterbur plant. However, caution needs to be employed when taking butterbur, according to Dr. Lipton. “The root has some toxic chemicals in it, so if the extraction is done incorrectly, it's not completely safe,” he says. Dr. Lipton recommends a German brand such as Weber & Weber because Germany regulates supplements more strictly than does the United States." (neurologynow)

Alternative supplements mentioned for possible helpfulness were B2 (riboflavin), magnesium, feverfew and coenzyme Q10.


 
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