Phenotype-driven preventive strategies for migraine and other headaches

Satisfactory prevention of migraine and other headaches is fraught with difficulties in the real world. Tolerability and safety issues are of concern just as is effectiveness or efficacy and all often seem to be patient-dependent. Maximizing migraine prevention and getting treatment right the first time ought to result in improved patient outcomes. Identifying headache phenotypes recognizes that clinical phenomenology may define or approximate genotypes that may predict specific preventive treatments.

The concept of phenotype-driven headache and migraine prevention relies heavily on the indomethacin-responsive headache experience wherein specific treatment is dictated by headache phenotype. Herein are described several additional headache phenotypes: migraine with typical and atypical aura, dopaminergic migraine, new daily-persistent headache, migraine with cluster or sinus features, short-lasting unilateral neuralgiform headache with conjunctival injection and tearing, hypnic headache, thunderclap headache, and imploding headache. Phenotype-driven preventive strategies are described that may offer reasonable first treatment choices, appropriate second choices, or choices when other treatments have failed.

These headache preventive recommendations are based on the best available evidence; however, all reports are observational. Perhaps some of these choices will be tested in prospective, randomized, blinded and controlled trials in the future, but historically clinical medicine has relied on clinical observations. The observations reported herein may help define specific, effective treatments for some patients or simply inspire further discussion and research about patient-specific preventive treatment regimens.