PRACTICE RECOMMENDATIONS
› Ask all patients with migraines about their use of complementary and alternative medicine and what modalities, if any, they have found helpful. A
› Advise patients that while butterbur has been proven effective at reducing migraine frequency, its use requires caution, as products not processed properly may contain hepatotoxic compounds. A
› Caution women who are pregnant or attempting to conceive to avoid feverfew, which may cause uterine contractions. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Americans who suffer from migraine headaches are far more likely than those who don’t to turn to complementary and alternative medicine (CAM). A 2007 National Health Interview Survey and a subsequent analysis of the results found that just under 50% of adults with migraine headaches used alternative therapies; among those without migraine, 34% did.1,2 What’s more, only about half of the migraine patients who reported the use of CAM modalities mentioned it to their health care providers.2
With migraine affecting some 36 million Americans,3 chances are you are caring for many of them. It is likely, too, that you are unaware of which of your headache patients are using alternative treatments, or what modalities they have tried. The only way to find out is to ask.
Women, who are 3 times more likely than men to suffer from migraine headache,4 are also the greatest users of CAM, particularly biologically based therapies and mind-body practices.5 Use is highly individualized and typically does not involve professional supervision.5
A number of alternative modalities look promising for migraine prevention. As a family physician, you are in an ideal position to guide patients in the use of safe and effective CAM therapies. To do so, however, you need to be familiar with the evidence for or against various options—many of which can be used in conjunction with pharmacotherapy.
An integrative approach to the treatment of migraine headaches makes use of the best available evidence for both conventional and alternative therapies and takes into account the whole person, including all aspects of his or her belief system and lifestyle. It also emphasizes a strong physician-patient relationship, which can have a powerful therapeutic effect.
We wrote this evidence-based update with such an approach in mind. In the text and table that follow, we present the latest findings. But first, a brief review of what constitutes migraine headache and an overview of conventional treatment.
A conventional approach to migraine
Migraine headache is a common and disabling neurologic disorder that frequently goes unrecognized and undertreated.6 It is generally characterized as recurrent headaches that are unilateral, pulsating, moderately severe, aggravated by physical activity, and associated with nausea, vomiting, photophobia, phonophobia, and sometimes a preceding aura. Conventional treatment typically includes abortive treatment for acute migraine, with medications such as the triptans and dihydroergotamine. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and the combination of acetaminophen/aspirin/caffeine are also effective. Opiates are efficacious, but not recommended.7
Prophylactic medications are generally offered to patients experiencing more than 4 migraines per month. The American Academy of Neurology cites strong evidence for the use of divalproex, valproate, topiramate, and beta-blockers, including metoprolol, propranolol, and timolol. Frovatriptan has strong evidence for prevention of menstrual-associated migraine. Common adverse effects include weight loss and parasthesias with topiramate and weight gain and somnolence with valproate, divalproex, and beta-blockers. There is also moderate evidence for the use of amitriptyline, venlafaxine, atenolol, and nadolol. Potential adverse effects must be considered to determine the optimal therapy for individual patients, and trial and error are often required.8
Addressing triggers
Conventional treatment also focuses on identifying and avoiding triggers to the extent possible. Physicians typically advise patients to keep a headache diary, recording details about diet and lifestyle, triggers, frequency and intensity of attacks, and possible patterns of headaches due to medication overuse.
Sleep disturbances and stress are common triggers, and instruction in sleep hygiene and stress reduction, as well as screening for anxiety or depression, can be beneficial. Other frequently reported factors believed to trigger or aggravate migraine attacks are skipping meals, particular foods, alcohol, weather changes, and exposure to light, sounds, and odors.
Despite the focus on migraine triggers, however, clinical studies of the role they play have shown conflicting results. A recent study involving 27 patients7 found that when attempting to provoke migraine with aura using participants’ self-reported triggers, only 3 individuals reported that the provocation actually led to a migraine.9 Additional studies suggest that exposure to headache triggers has the same effect as exposure to anxiety, with short-term exposure associated with an increased pain response and prolonged exposure leading to a decreased response.10,11 Thus, it may be beneficial to advise patients to learn to cope with controlled exposure to triggers rather than to aim for trigger avoidance.12