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| __NOTOC__ | | __NOTOC__ |
| {{Migraine}} | | {{Migraine}} |
| {{CMG}}
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| ==Overview==
| | The sections that follow describe our method for selecting migraine preventative therapy. |
| Following treatment of an acute migraine, it is important to consider preventive measures. Petasites are one of the preventive measures as well as medications such as [[NSAID]]s, [[amitryptilline]], [[devalproex]], [[valproic acid]], [[propranolol]], [[timolol]] and [[topiramate]] among others. If the preventive measure is not effective after two to three months, the dose of the medication should be adjusted. If no improvement is noted, another first line therapy or a combination of two first line therapies should be initiated.<ref name="pmid16417067">{{cite journal| author=Modi S, Lowder DM| title=Medications for migraine prophylaxis. | journal=Am Fam Physician | year= 2006 | volume= 73 | issue= 1 | pages= 72-8 | pmid=16417067 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16417067 }} </ref>
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| ==Pharmacological Prevention==
| | Selecting pharmacological treatment |
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| Following treatment of an acute migraine, it is important to consider preventive measures. Factors that prompt consideration of such measures include:
| | ===First-line agents=== |
| | We recommend [[amitriptyline]], [[venlafaxine]], one of the beta blockers [[propranolol]] or [[metoprolol]], [[topiramate]], or one of the [[calcitonin gene-related peptide]] (CGRP) antagonists as initial treatments for the majority of patients with episodic migraine (≤14 headache days per month) who meet the criteria for preventive therapy (see 'Indications' above). |
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| 1) More than two migraines per month with disabilities lasting three or more days per month;
| | As to the American Headache Society's 2024 position statement, we list CGRP antagonists [[erenumab]], [[fremanezumab]], [[galcanezumab]], [[eptinezumab]], [[rimegepant]], and [[atogepant]] as first-line alternatives.<ref name="PMID:38466028">{{cite journal |vauthors=Charles AC I |title=Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: An American Headache Society position statement update year=2024 |pmid=38466028 | doi: 10.1111/head.14692. Epub 2024 Mar 11 |url=}}</ref>. Numerous clinical trials, meta-analyses, and postapproval open-label cohort studies have demonstrated the effectiveness, safety, and tolerability of these medications.<ref name="PMID: 36063264">{{cite journal |vauthors=Murray AM I |title=Real-World Patient Experience of CGRP-Targeting Therapy for Migraine: a Narrative Review |pmid=38466028 | doi: 10.1007/s11916-022-01077-z. Epub 2022 Sep 5.|url=}}</ref><ref name="PMID: 36855951">{{cite journal |vauthors=Haghdoost F I |title=Evaluating the efficacy of CGRP mAbs and gepants for the preventive treatment of migraine: A systematic review and network meta-analysis of phase 3 randomised controlled trials |pmid=36855951 | doi: 10.1177/03331024231159366.|url=}}</ref> |
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| 2) Failure of acute treatments;
| | ===Second-line medications=== |
| | In patients who do not respond well to two or more first-line medications, or who do not respond well enough to them after at least eight weeks at a therapeutic dose, we recommend using second-line medications to prevent episodic migraine. Among these are additional antihypertensives including [[gabapentin]], [[venlafaxine]], [[candesartan]], [[lisinopril]], [[verapamil]], and [[valproate]]. |
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| 3) Contraindications to acute treatments;
| | ===Treatment failure=== |
| | For patients who do not improve after a sufficient trial of first pharmacologic therapy, we recommend switching to a migraine preventive medicine from a different class. Clinical trials have demonstrated that for those who have not responded to previous migraine preventive medications, switching to another preventive drug may be beneficial.<ref name="PMID: 22683887">{{cite journal |vauthors=Pringsheim T I |title=Canadian Headache Society guideline for migraine prophylaxis |PMID=22683887.|url=}}</ref> |
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| | ===Lifestyle measures=== |
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| 4) Adverse reactions from acute treatments;
| | Therapeutic lifestyle measures may be beneficial for controlling migraine, including good sleep hygiene, routine meal schedules, regular exercise, limiting caffeine intake, and managing migraine triggers. |
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| 5) Use of acute treatments more than twice a week;
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| 6) Presence of uncommon symptoms such as hemiplegia, prolonged, aura, or migraine infarction.
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| The main goal of preventive therapy is to reduce the frequency, severity, and durations of migraines, and to increase the effectiveness of abortive therapy. Another reason is to avoid medication overuse headache (MOH), otherwise known as [[rebound headache]], which is an extremely common problem among migraneurs. This occurs in part due to overuse of pain medications. MOH results in the development of chronic daily headache due to "transformed" migraine. Preventive medication has to be taken on a daily basis, usually for a few weeks, before the effectiveness can be determined. Supervision by a [[neurologist]] is advisable. A large number of medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next. Often preventive medications do not have to be taken indefinitely. Sometimes as little as six months of preventive therapy is enough to "break the headache cycle" and then they can be discontinued. The most effective prescription medications include several drug classes:
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| * [[Beta blockers]] such as [[propranolol]] and [[atenolol]]. A [[meta-analysis]] by the [[Cochrane Collaboration]] of nine [[randomized controlled trials]] or [[crossover studies]], which together included 668 patients, found that [[propranolol]] had an "overall [[relative risk]] of response to treatment (here called the 'responder ratio')" was 1.94.<ref name="pmid15106196">{{cite journal | author = Linde K, Rossnagel K | title = Propranolol for migraine prophylaxis. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD003225 | year = | id = PMID 15106196}}</ref>
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| * [[Anticonvulsants]] such as [[valproic acid]] and [[topiramate]]. A [[meta-analysis]] by the [[Cochrane Collaboration]] of ten [[randomized controlled trials]] or [[crossover studies]], which together included 1341 patients, found [[anticonvulsants]] had an "2.4 times more likely to experience a 50% or greater reduction in frequency with anticonvulsants than with placebo" and a [[number needed to treat]] of 3.8.<ref name="pmid15266476">{{cite journal | author = Chronicle E, Mulleners W | title = Anticonvulsant drugs for migraine prophylaxis. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD003226 | year = | id = PMID 15266476}}</ref> However, concerns have been raised about the marketing of [[gabapentin]].<ref name="pmid16908919">{{cite journal | author = Steinman M, Bero L, Chren M, Landefeld C | title = Narrative review: the promotion of gabapentin: an analysis of internal industry documents. | journal = Ann Intern Med | volume = 145 | issue = 4 | pages = 284-93 | year = 2006 | id = PMID 16908919}}</ref>
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| * [[Antidepressant]]s include [[tricyclic antidepressants]] (TCAs) such as [[amitriptyline]] and the newer [[selective serotonin reuptake inhibitors]] (SSRIs) such as [[fluoxetine]]. A [[meta-analysis]] by the [[Cochrane Collaboration]] found [[selective serotonin reuptake inhibitors]] are no more effective than placebo.<ref name="pmid16034880">{{cite journal | author = Moja P, Cusi C, Sterzi R, Canepari C | title = Selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headaches. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD002919 | year = | id = PMID 16034880}}</ref> Another [[meta-analysis]] found benefit from SSRIs among patients with migraine or tension headache; however, the effect of SSRIs on only migraines was not separately reported.<ref name="pmid11448661">{{cite journal | author = Tomkins G, Jackson J, O'Malley P, Balden E, Santoro J | title = Treatment of chronic headache with antidepressants: a meta-analysis. | journal = Am J Med | volume = 111 | issue = 1 | pages = 54-63 | year = 2001 | id = PMID 11448661}}</ref> A [[randomized controlled trial]] found that [[amitriptyline]] was better than placebo and similar to [[propranolol]].<ref name="pmid3579659">{{cite journal | author = Ziegler D, Hurwitz A, Hassanein R, Kodanaz H, Preskorn S, Mason J | title = Migraine prophylaxis. A comparison of propranolol and amitriptyline. | journal = Arch Neurol | volume = 44 | issue = 5 | pages = 486-9 | year = 1987 | id = PMID 3579659}}</ref>
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| Other drugs:
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| * [[Sansert]] was withdrawn from the US market by [[Novartis]], but is available in Canadian pharmacies. Although highly effective, it has rare but serious side effects, including [[retroperitoneal fibrosis]].
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| * [[Namenda]], memantine HCI tablets, which is used in the treatment of Alzheimer's Disease, is beginning to be used off label for the treatment of migraines. It has not yet been approved by the FDA for the treatment of migraines.
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| * [[ASA]] or [[Asprin]] can be taken daily in low doses such as 80 to 81 mg, the blood thinners in ASA has been shown to help some migrainures, especially those who have an aura.
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| ===NSAIDs and Complementary Drugs===
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| Shown below is an image depicting the classification of [[NSAID]]s and complementary drugs for migraine prevention according to the '''American Academy of Neurology''' and the '''American Headache Society'''.<ref name="pmid22529202">{{cite journal| author=Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E et al.| title=Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. | journal=Neurology | year= 2012 | volume= 78 | issue= 17 | pages= 1337-45 | pmid=22529202 | doi=10.1212/WNL.0b013e3182535d20 | pmc=PMC3335452 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22529202 }} </ref><ref name="pmid16417067">{{cite journal| author=Modi S, Lowder DM| title=Medications for migraine prophylaxis. | journal=Am Fam Physician | year= 2006 | volume= 73 | issue= 1 | pages= 72-8 | pmid=16417067 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16417067 }} </ref>
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| {|Class="wikitable"
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| |-
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| | '''Level A'''<br> '''Established efficacy'''
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| | '''Level B''' <br> '''Probable efficacy'''
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| | '''Level C''' <br> '''Possible efficacy'''
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| |-
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| |'''Petasites'''
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| *50 - 300mg BID <br>
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| *2.08 - 18.75 TID for MIG-99 preparation
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| |'''[[NSAID]]s'''
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| *[[Fenoprofen]]
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| **200 - 600mg
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| *[[Ibuprofen]]
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| **200mg twice a day
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| *[[Ketoprofen]]
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| **300mg three times a day
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| *[[Naproxen]]
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| **500 - 1100mg
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| *[[Naproxen sodium]]
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| **550mg twice a day
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| <br>
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| <br>
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| '''[[Histamine]]s'''
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| *[[Histamine]] SQ
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| **1 - 10ng twice a week
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| <br>
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| <br>
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| '''[[Vitamin]]s and [[Mineral]]s'''
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| *[[Riboflavin]]
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| **400mg per day
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| *[[Magnesium]]
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| **600mg per day
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| | '''[[NSAID]]s'''
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| * [[Flurbiprofen]]
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| * [[Mefenamic acid]]
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| <br>
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| <br>
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| '''Herbal therapies, vitamins, and minerals'''
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| * Co-Q10
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| * [[Estrogen]]
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| <br>
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| <br>
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| '''[[Antihistamines]]'''
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| *Cyproheptadine
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| |-
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| |}
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| ===Migraine Specific Therapies===
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| Shown below is an image depicting the classification of migraine specific therapies according to the '''American Academy of Neurology''' and the '''American Headache Society'''.<ref name="pmid22529202">{{cite journal| author=Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E et al.| title=Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. | journal=Neurology | year= 2012 | volume= 78 | issue= 17 | pages= 1337-45 | pmid=22529202 | doi=10.1212/WNL.0b013e3182535d20 | pmc=PMC3335452 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22529202 }} </ref><ref name="pmid16417067">{{cite journal| author=Modi S, Lowder DM| title=Medications for migraine prophylaxis. | journal=Am Fam Physician | year= 2006 | volume= 73 | issue= 1 | pages= 72-8 | pmid=16417067 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16417067 }} </ref>
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| {|Class="wikitable"
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| |-
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| | '''Level A'''<br> '''Established efficacy'''
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| | '''Level B''' <br> '''Probable efficacy'''
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| | '''Level C''' <br> '''Possible efficacy'''
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| |-
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| |'''[[Anticonvulsant|Anti-epileptic]]'''
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| *Divalproex sodium
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| **250 - 500mg twice a day
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| **Extended release - 500 - 1000mg per day
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| *[[Valproate semisodium|Sodium valproate]]
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| **250 - 500mg twice a day
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| *[[Topiramate]]
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| **50mg twice a day
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| <br>
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| <br>
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| '''[[Beta blockers]]'''
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| *[[Propanolol]]
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| **80-240mg per day (divided in 3 to 4 doses)
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| *[[Timolol]]
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| **10 - 15mg twice a day
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| *[[Metoprolol]]
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| **47.5 - 200mg per day
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| <br>
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| <br>
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| '''[[Triptan]]s'''
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| *Fovatriptan
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| **2.5mg per day
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| |'''[[Antidepressant]]s'''
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| *[[Amitriptyline]]
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| **25 - 150mg per day
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| *[[Venlafaxine]]
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| **150mg per day <br> (extended release)
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| <br>
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| <br>
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| '''[[Beta blockers]]'''
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| *[[Atenolol]]
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| **100mg per day
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| *[[Nadolol]]
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| **40 mg per day
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| <br>
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| <br>
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| '''[[Triptan]]s'''
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| *Naratriptan
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| **2.5mg per day
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| *Zolmitriptan
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| **2.5mg per day
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| |'''[[ACE inhibitors]]'''
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| *Lisinopril
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| <br>
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| <br>
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| '''[[Angiotensin receptor blocker ]]'''
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| *[[Candesartan]]
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| <br>
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| <br>
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| '''[[Alpha-adrenergic agonist|Alpha agonists]]'''
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| *Clonidine
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| *Guanfacine
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| <br>
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| <br>
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| '''[[Anticonvulsant|Anti-epileptic]]'''
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| *Carbamazepine
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| <br>
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| <br>
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| '''[[Beta Blockers]]'''
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| *Nebivolol
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| *Pindolol
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| <br>
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| <br>
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| '''[[Antihistamine]]s'''
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| *Cyproheptadine
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| |}
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| ===Menstruation Associated Migraine Specific Therapies===
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| Shown below is an image depicting the classification of migraine specific therapies recommended for short-term prevention of menstruation associated migraine according to the '''American Academy of Neurology''' and the '''American Headache Society'''.<ref name="pmid22529202">{{cite journal| author=Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E et al.| title=Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. | journal=Neurology | year= 2012 | volume= 78 | issue= 17 | pages= 1337-45 | pmid=22529202 | doi=10.1212/WNL.0b013e3182535d20 | pmc=PMC3335452 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22529202 }} </ref><ref name="pmid16417067">{{cite journal| author=Modi S, Lowder DM| title=Medications for migraine prophylaxis. | journal=Am Fam Physician | year= 2006 | volume= 73 | issue= 1 | pages= 72-8 | pmid=16417067 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16417067 }} </ref>
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| {| Class="wikitable"
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| |-
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| | '''Level'''
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| | '''Drugs'''
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| | '''Doses'''
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| |-
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| |'''Level A''' <br> '''Established efficacy'''
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| |[[Fovatriptan]]
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| |2.5mg bid perimenstrually
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| |-
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| |'''Level B''' <br> '''Probable efficacy'''
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| |[[Naratriptan]]
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| [[Zolmitriptan]]
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| |1mg bid for 5 days perimenstrually
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| 2.5mg bid or tidperimenstrually
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| |-
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| |'''Level C''' <br> '''Possible efficacy'''
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| |[[Estrogen]]
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| |1.5mg [[estradiol]] in gel for 7 days perimenstrually
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| |}
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| ===Side Effects===
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| {|Class="wikitable"
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| |-
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| | '''Side Effects'''
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| |-
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| |[[Anticonvulsant|Anti-epileptic]]
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| |Divalproex sodium <br>
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| * [[Hepatotoxicity]]
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| *[[Sedation]]
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| *[[Nausea]]
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| *[[Weight gain]]
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| *[[Teratology|Teratogenicity]]
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| ----
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| [[Valproate semisodium|Sodium valproate]]
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| *[[Hepatotoxicity]]
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| *[[Sedation]]
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| *[[Nausea]]
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| *[[Weight gain]]
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| *[[Teratology|Teratogenicity]]
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| ----
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| [[Topiramate]]
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| *[[Paresthesia]]
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| *[[Fatigue]]
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| *[[Nausea]]
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| |-
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| |[[Beta blockers]]
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| |[[Propanolol]]
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| *[[Fatigue]]
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| *[[Exercise intolerance]]
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| ----
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| [[Timolol]]
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| *[[Fatigue]]
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| *[[Exercise intolerance]]
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| ----
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| [[Metoprolol]]
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| *[[Fatigue]]
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| *[[Exercise intolerance]]
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| ----
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| [[Atenolol]]
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| *[[Blurred vision]]
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| *[[Confusion]]
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| *[[Dizziness]]
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| *[[Orthostatic hypotension]]
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| *[[Sweating]]
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| *[[Weakness]]
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| |-
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| |[[Antidepressant]]s
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| |[[Amitriptyline]]
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| *[[Weight gain]]
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| *[[Dry mouth|Xerostomia]]
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| *[[Sedation]]
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| ----
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| [[Venlafaxine]]
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| *[[Blurred vision]]
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| *[[Hypertension]]
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| |}
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| ==Non Pharmacological Prevention==
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| ===Physical Therapy===
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| Many physicians believe that [[exercise]] for 15-20 minutes per day is helpful for reducing the frequency of migraines.<ref>http://www.headachedrugs.com/pdf/HA2005.pdf] (PDF)</ref>[[Massage]] therapy and [[physical therapy]] are often very effective forms of treatment to reduce the frequency and intensity of migraines. However, it is important to be treated by a well-trained therapist who understands the pathophysiology of migraines. Deep massage can 'trigger' a migraine attack in a person who is not used to such treatments. It is advisable to start sessions as short in duration and then work up to longer treatments.Frequent migraines can leave the sufferer with a stiff neck which can cause stress headaches that can then exacerbate the migraines. Claims have been made that [[Myofascial Release]] can relieve this tension and in doing so reduce or eliminate the stress headache element.
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| === Prism Eyeglasses ===
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| At least two British studies have shown a relationship between the use of eyeglasses containing prisms and a reduction in migraine headaches. Turville, A. E. (1934) "Refraction and migraine". ''Br. J. Physiol. Opt.'' 8, 62–89, contains a good review of the literature and theories existing in 1934, and includes the vascular theory of migraine, which is popular today. In that study, Turville suggests that many patients were provided with complete relief from migraine symptoms with proper eyeglass prescriptions, which included prescribed prism. Wilmut, E. B. (1956) "Migraine". ''Br. J. Physiol. Opt.'' 13, 93–97, replicated Turville's work. Both studies are subject to criticism because of sample bias, sample size, and the lack of a control group. Neither study is available online, but another study that found that precision tinted lenses may be an effective migraine treatment and which references the Turville and Wilmut studies can be found at <ref name="urlwww.essex.ac.uk">{{cite web |url=http://www.essex.ac.uk/psychology/overlays/OPO.2002.22%20130-142.pdf |title=www.essex.ac.uk |format= |work= |accessdate=2012-08-30}}</ref> . Turville's and Wilmut's conclusions have largely been ignored since 1956 and it is widely believed that vision problems are not migraine triggers. Most optometrists avoid prescribing prism because, when incorrectly prescribed, it can cause headaches.
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| === Herbal and Nutritional Supplements ===
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| 50 mg or 75 mg/day of [[butterbur]] (''Petasites hybridus'') rhizome extract was shown in a controlled trial to provide 50% or more reduction in the number of migraines to 68% of participants in the 75 mg dose group, 56% in the 50 mg dose group and 49% in the placebo group after four months. Native butterbur contains some carcinogenic compounds, but a purified version, Petadolex®, does not. [[Cannabis]] was a standard treatment for migraines from the mid-19th century until it was outlawed in the early 20th century in the USA. It has been reported to help people through an attack by relieving the nausea and dulling the head pain, as well as possibly preventing the headache completely when used as soon as possible after the onset of pre-migraine symptoms, such as aura. There is some indication that semi-regular use may reduce the frequency of attacks. Further studies are being conducted. Some migraine sufferers report that cannabis increases throbbing and pain, especially if smoked. A pharmaceutical company is currently conducting trials of a whole cannabis extract spray for migraine. Supplementation of [[coenzyme Q10]] has been found to have a beneficial effect on the condition of some sufferers of migraines. In an [[open-label trial]],<ref name="CoenzymeRozen">{{cite journal | author = Rozen T, Oshinsky M, Gebeline C, Bradley K, Young W, Shechter A, Silberstein S | title = Open label trial of coenzyme Q10 as a migraine preventive. | journal = Cephalalgia | volume = 22 | issue = 2 | pages = 137-41 | year = 2002 | id = PMID 11972582}}</ref> Young and Silberstein found that 61.3% of patients treated with 100 mg/day had a greater than 50% reduction in number of days with migraine, making it more effective than most prescription prophylactics. Fewer than 1% reported any side effects. A double-blind placebo-controlled trial has also found positive results.<ref>{{cite journal |author=Sándor PS, et al.|title=Efficacy of coenzyme Q10 in migraine prophylaxis: A randomized controlled trial |journal=Neurology |volume=64 |pages=713-715 |year=2005 |url = http://www.neurology.org/cgi/content/abstract/64/4/713}}</ref>The plant [[feverfew]] (''Tanacetum parthenium'') is a traditional herbal remedy believed to reduce the frequency of migraine attacks. Clinical trials have been carried out (example<ref name="urlEfficacy and safety of 6.25 mg t.i.d. feverfew C... [Cephalalgia. 2005] - PubMed - NCBI">{{cite web |url=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16232154&query_hl=1&itool=pubmed_docsum |title=Efficacy and safety of 6.25 mg t.i.d. feverfew C... [Cephalalgia. 2005] - PubMed - NCBI |format= |work= |accessdate=2012-08-30}}</ref>), and appear to confirm that the effect is genuine (though it does not completely prevent attacks). [[Kudzu]] root (''Pueraria lobata'') has been demonstrated to help with menstrual migraine headaches and [[cluster headaches]]. While the studies on menstrual migraine assumed that kudzu acted by imitating estrogen, it has since been shown that kudzu has significant effects on the serotonin receptors. Kudzu Monograph at Med-Owl<ref name="urlCash Advance | Debt Consolidation | Insurance | Free Credit Report | Cell Phones at Med-Owl.com">{{cite web |url=http://www.med-owl.com/clusterheadaches/tiki-index.php?page=Kudzu |title=Cash Advance | Debt Consolidation | Insurance | Free Credit Report | Cell Phones at Med-Owl.com |format= |work= |accessdate=2012-08-30}}</ref>. [[Magnesium citrate]] has reduced the frequency of migraine in an experiment in which the magnesium citrate group received 600 mg per day oral of trimagnesium dicitrate. In weeks 9-12, the frequency of attacks was reduced by 41.6% in the magnesium citrate group and by 15.8% in the placebo group.<ref name="MagesiumPeikert">{{cite journal | author = Peikert A, Wilimzig C, Köhne-Volland R | title = Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study. | journal = Cephalalgia | volume = 16 | issue = 4 | pages = 257-63 | year = 1996 | id = PMID 8792038}}</ref> The supplement Riboflavin or [[Vitamin B2]] has also been used, often with magnesium citrate, to reduce the number of migraines. Its effectiveness is less well documented.
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| === Non-Drug Medical Treatments ===
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| [[Botulin toxin|Botox]] is being used by many headache specialists for patients with frequent or chronic migraines with encouraging results.<ref>Samton JB and Mauskop A. The treatment of headaches with Botulinum Toxin. Expert Review of Neurotherapeutics March 2006, Vol. 6, No. 3, Pages 313-322. </ref>[[Spinal Cord Stimulator|Spinal cord stimulator]]s are an implanted medical device sometimes used for those who suffer severe migraines several days each month.<ref name="SCSMatharu">{{cite journal | author=Matharu MS, Bartsch T, Ward N, Frackowiak RS, Weiner R, Goadsby PJ | title=Central neuromodulation in chronic migraine patients with suboccipital stimulators: a PET study | journal=Brain | year=2004 | pages=220-30 | volume=127 | issue=Pt 1 | id=PMID 14607792}}</ref>[[Transcranial magnetic stimulation|Transcranial Magnetic Stimulation]] (TMS): At the 49th Annual meeting of the [[American Headache Society]] in June 2006, scientists from Ohio State University Medical Center<ref name="urlThe Ohio State University Wexner Medical Center">{{cite web |url=http://medicalcenter.osu.edu/ |title=The Ohio State University Wexner Medical Center |format= |work= |accessdate=2012-08-30}}</ref> presented medical research on 47 candidates that demonstrated that TMS — a medically non-invasive technology for treating depression, [[obsessive compulsive disorder]] and [[tinnitus]], among other ailments — helped to prevent and even reduce the severity of migraines among its patients. This treatment essentially disrupts the aura phase of migraines before patients develop full-blown migraines.<ref name="urlTechnology | The Times">{{cite web |url=http://technology.timesonline.co.uk/article/0,,20409-2237003.html |title=Technology | The Times |format= |work= |accessdate=2012-08-30}}</ref> In about 74% of the migraine headaches, TMS was found to eliminate or reduce nausea and sensitivity to noise and light. Their research suggests that there is a strong neurological component to migraines. A larger study will be conducted soon to better assess TMS's complete effectiveness.<ref name="TMSMohammad">{{cite conference | first = Yousef | last = Mohammad | title = Magnets Zap Migraines | booktitle = 49th Annual Scientific Meeting of the [[American Headache Society]] | date = [[2006-06-22]] | location = [[Los Angeles]], [[California]] | url = http://researchnews.osu.edu/archive/headzap.htm | accessdate = 2006-07-04 }}</ref>
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| === Alternatives ===
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| Because the conventional approaches to migraine prevention are not 100% effective and can have unpleasant side effects, many seek alternative treatments.Some migraine sufferers find relief through [[acupuncture]], which is usually used to help prevent headaches from developing. Sometimes acupuncture is used to relieve the pain of an active migraine headache. In one controlled trial of acupuncture with a sham control in migraine, the acupuncture was not more effective than the sham acupuncture but was more effective than delayed acupuncture.Additionally [[acupressure]] is used by some for relief. For instance pressure between the thumbs and index finger to help subside headaches if the headache or migraine isn't too severe.Incense and scents are shown to help. The smell and incense of peppermint and lavender have been proven to help with migraines and headaches more so than most other scents. Mauskop A, Fox B, ''What Your Doctor May Not Tell You About Migraines''. Warner Books, New York, 2001
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| [[Biofeedback]] has been used successfully by some to control migraine symptoms through training and practice. Mauskop A, Fox B, ''What Your Doctor May Not Tell You About Migraines''. Warner Books, New York, 2001There is evidence that [[Magnesium in biological systems|magnesium]] supplements can reduce the frequency of migraine headaches. Riboflavin (vitamin B2), co-enzyme Q10 and butterbur extract has been also subjected to double-blind studies suggesting their efficacy in preventing migraine headaches. Mauskop A: "Alternative therapies in headache: Is there a role?" In: ''Medical Clinics of North America'' 85 (4): 1077-1084, 2001. Sleep is often a good solution if a migraine is not so severe as to prevent it, as when a person awakes the symptoms will have most likely subsided.[[Diet (nutrition)|Diet]], [[visualization (cam)|visualization]], and [[self-hypnosis]] are also alternative treatments and prevention approaches.[[Bruxism]], clenching or grinding of teeth, especially at night, is a trigger for many migraineurs. A device called a nociceptive trigeminal inhibitor (NTI) takes advantage of a reflex limiting the force of clenching. It can be fitted by dentists and clips over the front teeth at night, preventing contact between the back teeth. It has a success rate similar to butterbur and co-enzyme Q10, although it has not been subjected to the same rigorous testing as the supplements. Massage therapy of the jaw area can also reduce such pain.[[Sexual activity]] has been reported by a proportion of male and female migraine sufferers to relieve migraine pain significantly in some cases. In many cases where a migraine follows a particular cycle, attempting to interrupt the cycle may prolong the symptoms. Letting a headache "run its course" by not using painkillers can sometimes decrease the length of an episode. This is especially true of cases where vomiting is common, as often the headache will subside immediately after vomiting. Curbing the pain may delay vomiting, and prolong the headache.
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| ==References== | | ==References== |
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| [[Category:Needs overview]]
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| [[Category:Migraine]] | | [[Category:Migraine]] |
| [[Category:Primary care]]
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| [[Category:Neurology]] | | [[Category:Neurology]] |
| [[Category:Signs and symptoms]]
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| [[Category:Emergency medicine]] | | [[Category:Emergency medicine]] |
| [[Category:Disease]] | | [[Category:Disease]] |
| [[Category:Headaches]] | | [[Category:Headaches]] |
| [[Category:Head and neck]] | | [[Category:Head and neck]] |