Treatment of migraine with prophylactic drugs

Migraine is among the 10 most disabling disorders worldwide. Besides acute attack treatment, drug prophylaxis of migraine is important in order to improve the quality of life.

The aim of this paper is to describe the indications, principles and appropriate drugs with published evidence for the prophylaxis of migraine in general and in specific situations.

Based on the American and European guidelines for the treatment of migraine, the evidence for different drugs in the prophylaxis of migraine was evaluated. In addition, all trials on migraine drug prophylaxis published since the publication of the guidelines were included in the evaluation. These trials were identified by a literature search in MedLine, Embase and the Cochrane library.

The drugs of first choice are beta-blockers, flunarizine, valproic acid and topiramate and, in the US, amitriptyline is also grouped among the first-choice drugs. Drugs of second choice, with less efficacy or poorer evidence, are venlafaxine, gabapentin, naproxen, butterbur root, vitamin B(2) and magnesium. The potential side effects are considered when choosing the appropriate prophylactic drug. All drugs used in migraine prophylaxis have been detected by chance and not by pathophysiological considerations. In the future, drugs developed on the basis of the current knowledge of migraine pathophysiology will hopefully be more effective.