Peter L. Salgo, MD: Let’s talk about preventing migraines in the first place. When does preventive treatment become part of the treatment plan, and do you cover it?
Malaika Stoll, MD, MPA: Even before we talk about preventive medications, I think there’s the lifestyle and the triggers. For many people, migraines are triggered. You can identify what the triggers are. I think that’s where you always have to start before you throw the medications in.
Jill Dehlin, RN: I do the same thing. I say to have a diary. I tell patients to write down how many migraine days, or headache days, they experience and to log down what kind of medicines they’re using, on what days, and to note what kinds of effects the medicines may have had. Write down what kinds of foods you ate so you can keep track of possible dietary triggers. Do an elimination diet to try to figure out whether you have any triggers that you didn’t know about.
Malaika Stoll, MD, MPA: And then, of course, for women, we must look at menstrual migraines, hormones.
Jill Dehlin, RN: Weather.
Malaika Stoll, MD, MPA: Weather, right. For many people, you can go a long way with these lifestyle modification diaries.
Peter L. Salgo, MD: This has taken a turn that I didn’t expect. It’s fascinating that the first choice is lifestyle management. I was looking to get answers on drug therapies. In other words, it sounds easy, but it’s not. Keeping a diary is tricky. When you’ve got to write everything down, it’s tricky. At the end of the day, you get somebody to use a diary. You identify something that looks like a trigger, and you eliminate the trigger. How successful is that?
Jill Dehlin, RN: It’s pretty successful. MSG [monosodium glutamate] is a guaranteed trigger for me. Alcohol used to be a guaranteed trigger for me. And so you learn to avoid things that you know are associated with a migraine.
Peter L. Salgo, MD: But you wouldn’t know that unless you kept very careful records. Not everybody is capable of doing that, are they?
Jill Dehlin, RN: No.
Peter Goadsby, MD, PhD: Well, mobile apps are making that a bit easier, I think. I think you might be surprised if you walked down the street. You would be surprised if there weren’t a whole lot of people bumping into you as they were playing with their mobile phone. The advent of mobile apps is helping us with this. For some of the triggers that are punishing people, I think it’s right to advise them to have regular sleep, regular meals, and regular exercise. They need regularity. There will be a significant group of people who do their very, very best and do not improve very much.
Malaika Stoll, MD, MPA: Absolutely.
Peter Goadsby, MD, PhD: I think they shouldn’t be punished because they can’t fix it themselves. Let’s not throw it all back on the patient—that they have to fix themselves because they’ve got a biological problem.
Jill Dehlin, RN: Yes.
Peter L. Salgo, MD: Let’s go there. I was surprised that you could do this at all, and I’m delighted that it works. But there’s going to be a core group for whom it doesn’t.
Jill Dehlin, RN: Right.
Peter L. Salgo, MD: What do we do to prevent their migraines as best as possible, and how do you cover that?
Malaika Stoll, MD, MPA: Initially, as was discussed, we start with treating with over-the-counter options. We move on to triptans and other options when it’s a stronger headache. If that headache is more frequent, we move to preventive treatment. For example, I mentioned the beta-blockers and certain antidepressants but not all of them. Yes, we cover them. My health plan and most health plans cover them. Those are tried-and-true medications.
Peter L. Salgo, MD: Let me just go down a checklist. What about blood pressure drugs? Which drugs work? Are they the expensive drugs or the cheap drugs?
Malaika Stoll, MD, MPA: The classic beta-blockers, like atenolol, propranolol…
Peter L. Salgo, MD: These are cheap drugs. These are not very expensive.
Malaika Stoll, MD, MPA: These are generic, inexpensive drugs.
Peter Goadsby, MD, PhD: And candesartan. There were 2 placebo-controlled trials. It’s once-a-day dosing. It’s simple. It’s cheap as well. It’s a good medicine.
Malaika Stoll, MD, MPA: It’s an ARB [angiotensin receptor blocker].
Peter Goadsby, MD, PhD: Not all ARBs, quite interestingly, just candesartan.
Peter L. Salgo, MD: Not all ARBs. I knew that was coming.
Malaika Stoll, MD, MPA: It’s nuanced. It’s good.
Jill Dehlin, RN: And calcium channel blockers.
Malaika Stoll, MD, MPA: Yes, these are also tried-and-true.
Peter L. Salgo, MD: Any specific calcium channel blockers, or all calcium channel blockers?
Peter Goadsby, MD, PhD: Well, the last of the guidelines did point out that there was evidence that verapamil is woeful, at the very best. So it’s been moved into the uncertain category.
Jill Dehlin, RN: Oh, I stand corrected.
Peter Goadsby, MD, PhD: If you look at the evidence, it gets washed around.
Peter L. Salgo, MD: I was under the impression that a great many of the calcium channel blockers don’t cross the blood—brain barrier. If that’s the case, how do they work?
Peter Goadsby, MD, PhD: The only calcium channel blocker that has proven efficacy in migraine is a drug called flunarizine, which is not available in the United States. It does get into the brain. For all the ones that are available in the United States, there’s no evidence at all. The only evidence in verapamil is negative. Verapamil is a P-gp [P-glycoprotein] pumping substrate, so it gets pumped out.
Peter L. Salgo, MD: Very quickly, how do the antidepressants work? Which ones work?
Malaika Stoll, MD, MPA: The category would be the tricyclics. Amitriptyline was mentioned. That’s the most effective.
Peter L. Salgo, MD: And the antiseizure drugs? Which ones, and why do they work?
Peter Goadsby, MD, PhD: Topiramate has the best evidence and is the most widely prescribed preventive therapy for migraine in the United States. There’s evidence for valproate, but offering that to women when the adverse effects are weight gain, cognitive dysfunction, hair loss, and the chance for fetal abnormalities just doesn’t sound like a good idea.
Peter L. Salgo, MD: I’ll tell you, valproic acid is one of those drugs that are very old. It has an awful reputation. We know about this drug, and the next sentence was, “Don’t go there.”
Then there’s Botox. What’s going on with Botox?
Malaika Stoll, MD, MPA: There is good evidence for migraines that are refractory to some of the other preventive care that we’ve already mentioned.
Peter Goadsby, MD, PhD: Only for chronic migraine.
Peter L. Salgo, MD: Then we talked about topiramate, right?
Malaika Stoll, MD, MPA: Yes.
Peter L. Salgo, MD: Is there anything else, in terms of drug therapy, that we would use for chronic therapy or preventive therapy?
Malaika Stoll, MD, MPA: I’m curious as to what you would say on the use of contraceptive pills. Might they work for some women?
Peter Goadsby, MD, PhD: The oral contraceptive could help when it’s used back-to-back and you prevent menstruation if you’ve got menstrual-related headaches. So instead of taking a bleed, you back-to-back the pill and avoid the menstrual cycle. That can be helpful. For some women, however, it makes things worse. For some, it makes things better. It’s a bit unpredictable.
Jill Dehlin, RN: One of the issues that people with migraine have with using these preventive therapies that we’ve talked about is that it’s really trial and error.
Peter Goadsby, MD, PhD: Yes.
Jill Dehlin, RN: For migraine patients who are treated with topiramate, for example, you have to go low and slow and build up. You get up to 100 mg of therapy and find that you’re losing too much weight, you’re stupid, you can’t add, and you can’t function. You can’t just stop the drug. You’ve got to back off it very slowly. And then you try another drug. It’s the same thing over and over again. People are wary of that. They’re wary of the adverse effects. It’s very frustrating, and they feel like guinea pigs.