New approaches to migraine treatment on the horizon

NEW YORK (Reuters Health) – Effective migraine therapy remains elusive for some patients, according to physicians reporting in The New England Journal of Medicine for January 24. However, evidence of continuing underdiagnosis and undertreatment suggests that many of these patients can be helped. For those whose migraines do not respond to current treatment, early clinical trials of new treatment strategies offer hope.

Dr. Peter J. Goadsby, of the National Hospital for Neurology and Neurosurgery in London, and colleagues suggest assessing the severity and effects of migraine to devise the best treatment regimen. This can be done quickly by asking the patient to estimate the number of days over the past 3 months in which they missed work, school, or leisure activities or had to reduce their activity level because of migraine. Patients should also be asked to rate their average migraine pain on a scale of 0 to 10.

"In patients with migraine," the headache specialists write, "the brain does not seem to tolerate the peaks and troughs of life well." They recommend avoiding too much stress or relaxation, as well as regularity of sleep, meals and exercise. However, they warn, patients should not be not be given unrealistic expectations, because no matter what they do, migraines may continue to occur.

Prophylactic medications tend to be accompanied by "marked and intolerable side effects," Dr. Goadsby and his associates note. Such drugs include beta-adrenergic-receptor antagonists, amitriptyline, divalproex, serotonin antagonists, and flunarizine. Furthermore, only about two thirds of patients will experience a 50% reduction in the frequency of headaches.

The authors' advice is to base preventive treatment decisions on headache frequency, duration, severity and responsiveness to acute treatment. They suggest that serious consideration be given to prophylaxis if attacks occur at least five times per month.

Acute treatments include analgesic and nonsteroidal anti-inflammatory drugs, ergot derivatives, and triptans.

Dr. Goadsby's group points out that some patients remain refractory to treatment, and that what is really needed are antimigraine treatments with exclusively neural action. Initial trials with two "purely neural" compounds have yielded positive results. In addition, future treatments may involve blockade of nitric oxide synthesis or compounds that block the effects of calcitonin-gene-related peptide.

N Engl J Med 2002;346:257-268.

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