How many migraine patients need prolonged (>1 year) preventive treatment? Experience with topiramate

The usual recommended duration of preventive treatment for migraine is 3-6 months. Our aim was to explore how many patients attending a specialised clinic need prolonged preventive treatment for longer than one year. Eighty consecutive migraine patients who received preventive treatment with topiramate for 3 months with good response and tolerability were included in this observational study. All patients continued on topiramate until they had completed 6 months, when this drug was stopped. Topiramate was reintroduced if there was a worsening. Topiramate was kept for 6 more months and then discontinued again. Those patients whose headaches became worse after this second withdrawal received topiramate again and were followed-up for at least half a year. Headaches did not worsen after the first withdrawal at 6 months in 40 patients (50%), while they clearly worsened in the remaining 40 patients. At the end of the first year only two patients out of these 40 (5%) discontinued topiramate and did not notice an increase in headache frequency after two months. In conclusion, around half of the patients attending a specialised clinic due to frequent headache need preventive treatment for more than one year. Our data suggest that the current practice recommending periods of preventive treatment of 3-6 months should be reconsidered for many patients.