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December 2005

Nonpharmacologic treatment of migraine.

Nonpharmacologic treatment of migraine is often used by patients and can provide interesting options for physicians. Knowledge about the evidence and its absence is important. Avoidance of trigger factors can help, if individualized. Behavioral approaches, such as relaxation techniques, biofeedback, and cognitive-behavioral therapy, require far more specialist time or technical devices, but are supported by some evidence, which is mostly old. The same is true for hypnosis. A n ew approach in migraine prevention is aerobic exercise, which is associated with positive side effects. Whether it will take a strong role, similar to the treatment of depression, remains to be seen. There is no convincing evidence for the efficacy of spinal manipulation. Hyperbaric oxygen may be an effective, but rarely practical prophylactic measure. The evidence pertaining to the efficacy of acupuncture is controversial because of methodologic difficulties, but an ongoing large German study may provide valuable evidence in the near future. Nutritional supplements acting on mitochondrial metabolism, such as magnesium, riboflavin, and coenzyme Q10, were shown to be effective in small, randomized, controlled trials. More studies on the different therapeutic interventions are needed, using modern diagnostic standards and state-of-the-art trial methodology.

Curr Pain Headache Rep. 2005 Jun;9(3):202-5

Treatment strategies in migraine patients.

The goal of migraine treatment is to alleviate the symptoms of acute attacks and improve patients' quality of life. Therapeutic options and strategies principally rely on three types of approach: correction of causative factors; acute treatment of attacks; and prophylaxis. The quality of evidence supporting efficacy, personal experience, tolerability and safety profiles must guide the choice of a particular medication; nonetheless, we ought to keep in mind that therapeutic options should also be customized to target the individual patient, both in terms of personal characteristics and underlying comorbidities. Also, the fram ework of information the patient is given represents an essential component of migraine management, along with his/her active involvement in the therapeutic program and schedule.

Neurol Sci. 2004 Oct;25 Suppl 3:S242-3

Diagnosis and management of migraine headaches.

Migraine headaches afflict approximately 6% of men and 18% of women in the United States, and cost billions of dollars each year in lost productivity, absenteeism, and direct medical expenditures. Despite its prevalence and the availability of therapeutic options, many patients do not seek treatment, and among those who do, a significant portion are misdiagnosed. Correct diagnosis can be made by identifying the historic and physical examination finding that distinguish primary headache disorders from secondary head ache disorders, as well as the key clinical features that distinguis migraine headaches from other types. Once diagnosis is made, improper or inadequate management of headache pain, related symptoms such as nausea, and the possible aggravating side-effects of pharmacologic therapies represent further obstacles to effective therapy. Dissatisfaction with migraine therapy on the basis of these factors is common. Among abortive therapy options there are de livery methods available which may avoid aggravating symptom such as nausea. Recommended pharmacologic agents include non steroidal anti-inflammatory drugs, intranasal butorphanol, ergota mine and its derivatives, and the triptans. Indications for prophylactic in addition to abortive therapy include the occurrence o headaches that require abortive therapy more than twice a week, that do not respond well to abortive therapy, and which are particularly severe. Research is ongoing in the pathophysiology of migraines evaluation of nonpharmacologic treatment modalities, assessment of n ew drug therapies, and validation of headache guidelines.

South Med J. 2004 Nov;97(11):1069-77

Challenging or difficult headache patients.

This article addresses interesting and enigmatic presentations of headache from a diagnostic and treatment perspective. The emphasis is on migraineurs and other headache patients who represent a significant burden for the primary care provider. In particular, the author focuses on undiagnosed migraine, menstrual migraine, migraine in pregnancy, intractable migraine and status migrainosus,transformed migraine, hemiplegic migraine, basilar migraine, “riptan syndrome,” sudden onset of severe headache, post-traumatic headache, and headache in elderly patients.

Prim Care. 2004 Jun;31(2):429-40

Migraine headaches: nutritional, botanical, and other alternative approaches.

Migraine headaches are an increasingly common health problem with a wide range of potential etiological factors. Stress, food allergies, neuroendocrine imbalances, and nutritional deficiencies all may contribute to migraine attacks. Many nutritional and botanical therapies aim to reduce migraine incidence by decreasing platelet aggregation and preventing the release of vasoactive neurotransmitters, and avoiding triggering foods. This article revi ews much of the research on nutritional, botanical, dietary, and other alternative approaches to the treatment and prevention of migraines.

Altern Med Rev. 1999 Apr;4(2):86-95

Etiology and pathogenesis of cluster headache.

This last decade has seen remarkable progress made toward unraveling the mystery of primary headache disorders like migraine and cluster. The vascular theory has been superseded by recognition that neurovascular phenomena seem to be the permissive and triggering factors in migraine and cluster headache. This understanding has been achieved through n ew imaging modalities such as positron emission tomography and functional magnetic resonance imaging. Prior to these imaging techniques it was impossible to study the primary headache disorders because these had no structural basis. There is now an increasing body of evidence that the brain is involved primarily in cluster and migraine and that vessel dilatation is an epiphenomenon.

Curr Pain Headache Rep. 2002 Feb;6(1):71-5