Headache guidelines

Stephen D Silberstein MD (Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, receives honorariums from Allergan, Avanir Pharmaceuticals, Curelator, Depomed, Dr. Reddy's Laboratories, eNeura,  INSYS Therapeutics, Lilly USA, Supernus Pharmacerticals,  Thernica and Trigemina for consulting. He is also the  principal investigator for a clinical trials conducted by Alder Biopharmaceuticals, Amgen, electroCore Medical, Lily USA and Teva.)
Originally released February 28, 2001; last updated: March 25, 2014; expires March 25, 2017
Notice: This article has expired and is therefore not available for CME credit.

This article updates the results from the 4 evidence-based reviews on the management of patients with migraine: specifically, acute, preventive, and nonpharmacologic treatments for migraine, as well as the role of neuroimaging in patients with headache. The full papers for these treatment guidelines are published elsewhere (Campbell et al 2000; Frishberg et al 2000; Matchar et al 2000; McCrory et al 2000; Ramadan et al 2000; Silberstein and Rosenberg 2000), and only the specific treatment recommendations are summarized below (Holland et al 2012; Silberstein et al 2012).

In June 1998, Duke University's Center for Clinical Health Policy Research, in collaboration with the American Academy of Neurology, completed 4 Technical Reviews on migraine sponsored by the Agency for Health Care Policy and Research: self-administered drug treatments for acute migraine (Gray et al 1999a); parenteral drug treatments for acute migraine (Gray et al 1999b); drug treatments for the prevention of migraine (Gray et al 1999c); and behavioral and physical treatments for migraine (Goslin et al 1999). The Education and Research Foundation of the American Academy of Neurology later funded additional reports on diagnostic testing for headache patients, an update on sumatriptan and other 5-HT1 agonists, and a report on butalbital-containing compounds for migraine and tension-type headache, using the same methodology that was used in the original Technical Reviews. A multidisciplinary panel of professional organizations (The US Headache Consortium) produced 4 treatment guidelines, each related to a distinct set of management decisions: diagnostic testing (primarily neuroimaging studies), pharmacological management of acute attacks, migraine-preventive drugs, and behavioral and physical treatments for migraine.

In 2012, the American Academy of Neurology updated and published new preventive treatment guidelines for migraine (Holland et al 2012; Silberstein et al 2012). For pharmacologic therapy, the authors analyzed published studies from June 1999 to May 2009, using a structured review process to classify the evidence relative to the various medications available in the United States for migraine prevention. The author panel reviewed 284 abstracts, which ultimately yielded 30 Class I or Class II articles that are reviewed herein.

The original search identified 179 articles. A supplemental search (2007 to 2009) yielded 105 additional articles. Of the total 284 articles, 30 were pharmacologic and were classified as Class I or Class II and are reviewed herein. In addition, 15 were classified as Class I or Class II and identified as relating to nonsteroidal anti-inflammatory drugs (NSAIDs) and complementary treatments.

Studies were excluded if they included any of the following factors:


• Assessed the efficacy of therapeutic agents for headache other than episodic migraine in adults


• Assessed acute migraine treatment, migraine aura treatment/prevention, or nonpharmacologic treatments (eg, behavioral approaches)


• Used quality of life measures, disability assessment, or nonstandardized outcomes as primary efficacy endpoints


• Tested the efficacy of drugs not available in the United States

Since the guideline publication in 2000, the AAN revised its evidence classification criteria to include study completion rates. Studies with completion rates below 80% were downgraded; thus, several studies in the original guideline have been downgraded.

They found no new Class I or II studies published for acebutolol, atenolol, bisoprolol, carbamazepine, clonazepam, clonidine, clomipramine, fluvoxamine, guanfacine, nabumetone, nadolol, nicardipine, nifedipine, or protriptyline. Recommendations for these agents are based on the evidence reviewed in the original guideline (denoted with an asterisk in Table 1). Currently, no Class I or Class II studies exist for anticoagulants (limited Class III and IV studies were identified; Table 1 includes anticoagulants). Of the total 284 articles, 15 were classified as Class I or Class II and identified as relating to NSAIDs and complementary treatments; they are reviewed herein.

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