American Academy of Neurology Report on Migraine Prevention

This week a group of headache specialists, some of whom I’ve worked with in the past, published the follow landmark article in the Journal of Neurology (also known as the “green journal”): 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. You can click on the title to read the entire article.

You may not have noticed but there have been several mentions of this article in the media and I have had a few patients calling about it. I wanted to put it into perspective.

The purpose of the article was trying to create category of evidence for the usefulness of drugs in preventing episodic migraines.  The focus is simply on the empirical evidence as shown by well designed studies. Therefore I think everything included in the article can be trusted.

Now to the limitations.  I know the authors of this article and if you watch the way they treat their own patients, they, like all of us headache specialist, don’t follow this guide verbatim.  The reason is, some of the medications mentioned, while having decent evidence of being effective, have side effects and other issues that were not addressed here.  There are also many medications that we are confident that do work, are safe, yet lack the hard-core evidence as examined here.

The major reason that some drugs carried excellent data to support their effectiveness is necessarily related their over-all superiority but related to the fact that the company that made the original branded drug invested the money, sometimes over $100,000,000, to do the good studies.  Many medications are generic and no one has the kind of money or interest in doing the big studies to prove that they are effective.  Other drugs, the manufacturers simply were not interested in doing studies.

It is uncommon that a group of individual headache specialist can create big, nationwide (or what we call multi-centered) studies because it is cost prohibited. So while this article is a good place to start the discussion, and may act as a guide to those who are not trained in headache medicine, it is not meant to be a “cook book” for how to treat headaches.  There is an art that develops when you have done this for years.