Six Years in the Making: New Episodic Migraine Guidelines

Andrew N. Wilner, MD; David W. Dodick, MD


May 15, 2012

In This Article

Editor's Note:

At the 2012 Annual Meeting of the American Academy of Neurology (AAN) in New Orleans, Louisiana, Andrew Wilner, MD, on behalf of Medscape, spoke with David W. Dodick, MD, Professor of Neurology at Mayo Clinic in Phoenix, Arizona, on new guidelines developed jointly by the AAN and the American Headache Society for the prevention of episodic migraine. The biggest surprise? Make room for an herbal.

Dr. Wilner: I'd like to ask you a few questions about the new migraine headache guidelines,[1] which were released here at the AAN meeting in New Orleans and which are for people who have episodic migraine. But first, what is episodic migraine?

Dr. Dodick: If you look in the International Headache Classification, they don't use the term "episodic migraine." We tend to use that term in clinical practice because we try to distinguish it from chronic migraine, which does have a definition. Chronic migraine occurs in patients who have 15 or more headache days per month. It is an arbitrary line drawn in the sand of 15 days, so episodic migraine refers to patients who have 14 or fewer days of headache per month.

Dr. Wilner: It sounds as though most migraine patients would be episodic rather than chronic. Is that correct?

Dr. Dodick: Yes, that is correct. The prevalence of migraine is about 12%, so that is 36 million Americans. The prevalence of chronic migraine is approximately 2%. Now, 2% sounds like a small number compared with 12%, but it is still a lot of patients. There are many sufferers. We are talking about 6 million people, perhaps, in the United States, so that is a lot of people suffering with a very chronic and disabling illness.

Dr. Wilner: Dr. Stephen Silberstein spoke earlier about this at the meeting. There are 2 approaches to the treatment of migraine: One is to treat the headache when it occurs, and the other is prophylactic treatment in which the patient takes medication every day to prevent migraine. Could you summarize the major findings of the guideline in terms of the evidence base for how to proceed?

Dr. Dodick: Basically, the guideline provides levels of evidence based on the strengths of the studies that have been done for a variety of different medications, supplements, herbs, and minerals. It provides the evidence base for the use of those compounds for the prevention of migraine.

When we say "prevention of migraine," we mean medications, supplements, minerals, or herbs that are taken daily to reduce the frequency, severity, and duration of attacks. An effective preventive medication invariably will not just reduce the frequency of attacks, but it will make those attacks that do break through milder, shorter in duration, and more responsive to acute medication. The attacks that people do experience while they are on preventive medication may be much less disabling.

The guideline summarizes the levels of evidence for a litany of different medications and drugs. For example, very strong evidence supports the use of the level A medications, including antiepileptic drugs such as topiramate and divalproex sodium.

Dr. Wilner: Both of which are US Food and Drug Administration (FDA) approved.

Dr. Dodick: The other FDA-approved medications are propranolol and timolol, which are beta-blockers. We have added one more beta-blocker to the list of drugs with level A evidence: metoprolol. We have actually added a supplement as well -- an herb -- to that level A group, and that is Petasites, or butterbur.


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