Possible precipitation of migraine attacks with prophylactic treatment

The initiation of a prophylactic treatment in a migraine sufferer depends upon the stratification of the patient's frequency of attacks and the disability they cause, as well as the patient's acute consumption and comorbid diseases. We report on 14 patients who were among a group of 618 migraine sufferers who received a new preventative treatment. These 14 patients developed an increase in the frequency of their migraine attacks that was possibly induced by this new prophylactic treatment. The clinical description of the migraine attacks remained the same but the frequency of the attacks of migraine without aura was dramatically increased. This is, to our knowledge, the first description of a possible precipitation of attacks of migraine without aura with a prophylactic treatment. There is no link with a specific class of prophylactic treatment. We hypothesize that the migraine sufferers who experienced aggravation after the new prophylactic drug had been introduced had a paradoxical decrease in the induction threshold for cortical spreading depression (CSD). Mechanisms of such a decrease are unknown and are probably multifactorial, but changes in serotonin neurotransmission have been experimentally demonstrated to modify cortical excitability and favour CSD. The aggravation was described only for attacks without aura. However, with only 14 patients, it is not possible to predict whether suffering from that the type of migraine is a factor that predisposes a patient to aggravation. While additional cases are necessary, physicians should be aware of the possibility that prophylactic treatment may exacerbate migraine attacks.