Topics in migraine management: a survey of headache specialists highlights some controversies

The authors' Survey of headache specialists highlights a number of controversial issues in migraine management including the following: acute treatment, focusing on use of triptans, and preventative medications; treatment of migraine with prolonged aura and basilar migraine; and the use of oral contraceptives in migraine. Interestingly, the prevalence of migraine among the headache specialists themselves is much higher than in the general population. Although triptans have revolutionized the acute treatment of migraine, treatment is still problematic for the sizable percentages of patients with an incomplete or no response and recurrence of headache. Triptans are generally very safe when the physician, aware of the potential for coronary artery vasoconstriction, appropriately screens patients before and during their use. Serotonin syndrome as a complication of triptan use is quite rare. Although there is no definite evidence of teratogenesis, triptans should not be taken during pregnancy unless the potential benefit justifies the potential risk to the fetus. Caution is also advised when using a triptan during breastfeeding. The United States Headache Consortium parameters, which consider indications for preventative treatment and propose general principles of management, are reviewed. Unfortunately, the experience of many migraineurs with preventative medications is less than satisfactory because of side effects or lack of efficacy. Treatment of both migraine with prolonged aura and basilar migraine is anecdotally based. Many headache specialists do not use beta blockers for prevention for those with prolonged aura and basilar migraines because of concerns over the potential limitation of compensatory vasodilatory capacitance. There are seven case reports in the literature of an association between stroke and the use of beta blockers in migraineurs. Prevention using divalproex sodium and verapamil is favored by many headache specialists. Triptans are contraindicated in the treatment of patients with hemiplegic or basilar migraine because of concern over the potential for cerebral vasoconstriction. The frequency of migraine is usually unchanged with the use of oral contraceptives although, occasionally, migraine may occur for the first time or increase in frequency. Studies have produced conflicting results as to whether low-dose estrogen oral contraception increases the risk of stroke. Migraine alone increases the risk of stroke, at least in women under the age of 45 years. Most women with migraine without aura and migraine with visual aura lasting less than 1 hour can safely use low-dose estrogen oral contraceptives when there are no other contraindications. Those with aura symptoms such as hemiparesis or dysphasia or prolonged focal neurologic symptoms and signs lasting more than 1 hour should avoid starting low-dose estrogen oral contraceptives and stop the medication if they are already taking it.