Clinical considerations preliminary to application of the Italian Society for the Study of Headache's guidelines regarding migraine prophylactic treatment

Abstract

IntroductionThis paper provides some clinical suggestions regarding the prescription of prophylactic headache treatment. The paper is directed to primary care physicians and to algologists who do not currently manage headache, and is based on the scientific evidence as summarized in the clinical guidelines elaborated by the Italian Society for the Study of Headache [1,2]. Indication for migraine prophylaxis: what should be achieved?The main goals of prophylactic treatment for migraine are to decrease headache attack frequency, length and intensity, to improve the efficacy of symptomatic drugs, to prevent the frequent intake of analgesic and specific migraine drugs, and to prevent the episodic headache from turning into chronic headache [2, 3]. Therefore, clinical evaluation of the patient, regarding the frequency, length and intensity of their headache attacks, is preliminary to the evaluation of treatment efficacy. In randomised clinical trials, a good answer to prophylactic treatment is evaluated as a 50% responder rate in 50% of the treated subjects [4,5].In everyday clinical practice, we often observe that in the vast majority of patients migraine does not have a constant trend and its time-related evolution depends on trigger factors often contingent and not foreseeable in the single subject. Only an adequately compiled headache diary concerning the previous months can reveal eventual pain cycles and help in deciding the preventive treatment start time and length [6]. If this record is not available, we believe that there is a risk of prescribing an ineffective drug too long or, quite the opposite, of discontinuing the treatment before the time necessary to observe the desired response to a potentially effective drug.Adequate therapeutic choices are not easy, even when specific guidelines are available. First of all, it is necessary to decide if, when and how to begin a prophylactic treatment, but on this point there are no absolute indications [2]. Abstract The main goals of prophylactic treatment for migraine are to decrease headache attack frequency, length and intensity, to improve the efficacy of symptomatic drugs, to reduce their need, and to prevent pain chronicization. Therefore, the choice of a prophylactic drug and the modality of treatment is not easy and often not adequately supported by literature data nor by current national and international guidelines. Moreover, the response of the migraine patient to treatment is often unforeseeable. The aim of this short review is to provide some practical suggestions to the physician regarding how to decide when to begin a migraine prophylactic treatment and how to apply the specific guidelines of the Italian Society for the Study of Headache.