3 According to the criteria of the International Headache Society, 1 medication overuse headache is defined as headache present on more than 15 days per month, which has developed or markedly worsened during medication overuse. Prophylactic therapy should be considered for patients whose migraine episodes have a substantial impact on their lives (i.e., causing them to miss workdays and family activities) despite appropriate use of symptomatic medications, or whose frequency of episodes is such that reliance on acute medications alone puts them at risk for medication overuse headache. Lifestyle factors, including stress, meal-skipping, obesity, and erratic sleep and work schedules, can precipitate migraine. Common headache triggers include caffeine withdrawal, alcohol, sunlight, menstruation and changes in barometric pressure. All patients for whom migraine prophylactic agents are considered should be educated in migraine triggers and lifestyle-related factors. Prophylactic medications are no substitute for attention to patient lifestyle and avoidance of migraine triggers. Evidence on which to base this decision is lacking, and many medications are available from which to choose. When prophylaxis should be started is a matter of clinical judgement. 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. When symptomatic medications are used too frequently, they can result in increased frequency of headache and medication overuse headache. ![]() Patients who have frequent episodes of migraine may sustain substantial disability despite appropriate symptomatic therapy. Symptomatic migraine therapy alone, although helpful for many patients, is not adequate treatment for all. 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. Existing guidelines on this topic are out of date 2 or do not include a systematic review of the literature. 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. Headache is not attributable to another disorder Although valid randomized controlled trials exist to aid decision-making, all of the medications used in treatment have incomplete efficacy, and most produce adverse effects. Prophylactic therapy for migraine remains one of the more difficult aspects. When migraine episodes are frequent, treatment can be challenging. The diagnostic criteria for migraine headache 1 according to the International Headache Society are shown in Box 1. Migraine headache is a common, disabling condition. Which prophylactic medication should be tried first? ![]() Physical examination is normal except for obesity. She generally sleeps well and has no history of clinically significant mood disturbance. The patient’s medical history includes asthma that is well controlled. 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 headache diary shows that she takes a triptan nine days per month. Occasionally the headaches did not respond well to the triptan they caused the patient to miss work about once per month. Sometimes the headache returned the next day, necessitating a second dose. The headaches occurred once or twice per week, but usually responded well to a triptan taken soon after onset. A 40-year-old woman presented with an eight-year history of migraine headaches.
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