Pharmacologic and Complementary Therapy for Migraine Prophylaxis

Amne Borghol, PharmD, CGP; Breannie Charles, PharmD; Fadi Hawawini, DO


US Pharmacist. 2013;38(1):23-27. 

In This Article

Abstract and Introduction


Migraine, a chronic neurologic disorder, involves episodic attacks of headache and associated symptoms. Although almost 26% of migraine patients fulfill criteria for preventive therapy, only one-half of sufferers use daily preventive medications. Triptans, antidepressants, antiepileptic medications, nonsteroidal anti-inflammatory drugs (NSAIDs), antiemetics, opioids, and cardiovascular agents have been investigated for migraine prophylaxis. In 2012, the American Academy of Neurology and the American Headache Society published updated evidence-based recommendations for episodic migraine prevention classified according to seven levels. Pharmacologic agents, NSAIDs, and complementary therapies are included in the revised guidelines. The guidelines also address new therapies for the short-term prevention of menstrually associated migraines, including frovatriptan, naratriptan, and zolmitriptan.


Migraine is a chronic neurologic disorder characterized by episodic attacks of headache and associated symptoms such as aura, nausea, vomiting, and photophobia. Extensive research has been conducted not only on how to treat migraine episodes, but also on how to prevent or reduce the number of occurrences. According to recent studies, nearly 26% of migraineurs meet the criteria for preventive therapy, but only 13% actually use daily preventive medications.[1] Medications that have been investigated for migraine prophylaxis include nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, antidepressants, opioids, antiepileptic drugs (AEDs), antiemetics, and cardiovascular medications.

The American Academy of Neurology (AAN) published guidelines on episodic migraine prevention in adults in 2000.[2] In 2012, the Quality Standards Subcommittee of the AAN and the American Headache Society (AHS) published revised evidence-based recommendations for episodic migraine prevention that upgraded or downgraded current pharmacologic agents and added new agents. Based on study results reviewed by the panel, pharmacologic agents were classified into seven recommendation categories (levels A, B, C, U, A negative, B negative, C negative) relative to their efficacy for migraine prophylaxis (Table 1).[2]

The new guidelines also included recommendations concerning the clinical efficacy of NSAIDs and complementary therapies (i.e., herbals, vitamins, minerals) for episodic migraine prophylaxis based on new evidencebased clinical trials.[3] Treatments addressed were the NSAIDs fenoprofen, ibuprofen, ketoprofen, naproxen, and naproxen sodium; subcutaneous histamine; and the complementary therapies Petasites hybridus extract (butterbur), MIG-99 (feverfew), riboflavin (vitamin B), and magnesium.[3]