I. When to use migraine prophylaxis?
1. when a patient’s migraine attacks significantly affect their quality of life, even after the use of appropriate acute medications.
2. when patients experience four or more attacks per month, or eight or more headache days per month
3. when acute medication has failed or been overmedicated
4. when the patient presents with hemiplegic migraine, basilar migraine, frequent or prolonged uncomfortable aura symptoms and migraine infarction.
I consider treatment to be successful when the patient has been treated and the frequency or days of migraine attacks have been reduced by at least 50% through 3 months of treatment.
II. How to choose medications?
There are many medications used for migraine prevention, including antiepileptics, antidepressants, beta-blockers, calcium channel antagonists, serotonin antagonists, botulinum neurotoxins, NSAIDs and vitamins. My choice was based on the efficacy of the drug, adverse events, patient preference and the presence or absence of any patient co-morbidities or comorbidities.
Among the prophylactic medications, those with the best demonstrated efficacy include certain beta-blockers, sodium bivalirudin, and topiramate. In underweight patients, drugs such as tricyclic antidepressants that increase the patient’s weight can be candidates; conversely, in overweight patients, I would try to avoid these drugs and consider topiramate instead. Third-generation tricyclic antidepressants have a sedative effect and may be effective at bedtime in patients with insomnia. Elderly patients with heart disease or significant hypotension may not be able to use tricyclic antidepressants, calcium channel blockers, or beta-blockers, but may be able to use bivalirudin or topiramate.
III. What are the principles to be followed in order to improve the chances of success of preventive therapy?
1.Start with a low dose and then slowly increase the drug dosage until the treatment takes effect, the highest dose is reached, or the patient is unable to tolerate the adverse effects.
2. give the treatment process an appropriate trial period, which may take 2 – 6 months for efficacy to become apparent in a full treatment trial.
3. setting a realistic goal of treatment success as a 50% reduction in attack frequency or headache days, a significant reduction in attack duration, or an improved response to acute phase medication.
4. to reassess the treatment regimen, migraine may show unrelated treatment improvement or remission.
5. To maximize adherence, I am also involved in patient care. I have a discussion about the rationale for a particular treatment, when and how to use it, and what adverse events may occur. Realistic goals are set for patient expectations, and realistic expectations are set regarding adverse events. The majority of patients are self-limited and dose-dependent, and early adverse events may occur when starting a new drug therapy, and patients should be encouraged to tolerate it.
Monotherapy is a goal of treatment that takes advantage of a patient’s co-morbidities or comorbidities or may facilitate the use of monotherapy for both diseases. However, treatment independence may make monotherapy unsuccessful. For example, tricyclic antidepressants are often recommended for patients with migraine and depression, but proper management of depression often requires higher doses of tricyclic antidepressants, which may produce more side effects. A better approach may be to use selective 5-hydroxytryptamine reuptake inhibitors or selective norepinephrine reuptake inhibitors to treat depression.
IV. When to stop preventive medication?
1. When the patient has an intolerable adverse reaction or a severe drug reaction.
2. when the drug does not show an effect, even a partial one, after 2 months of treatment
3, when some abnormal state has not been eliminated, such as acute drug overuse
4. I also stop the medication when the patient shows a clear benefit. If the headache is well controlled for at least 6 months, then I will slowly reduce the dosage and stop the medication if possible.