[Treatment guidelines for preventive treatment of migraine].Acta Neurol Taiwan. 2008 Jun; 17(2):132-48.AN
The Treatment Guideline Subcommittee of the Taiwan Headache Society evaluated the medications currently used for preventive therapy of migraine in Taiwan according to the principles of evidence-based medicine. We assessed the quality of clinical trials, levels of evidence, and referred to other treatment guidelines proposed by Western countries. Throughout several panel discussions, we merged opinions from the subcommittee members in order to propose a Taiwan consensus about the major roles, recommended levels, clinical efficacy, adverse events and cautions of clinical practice for these medications in preventive treatment of migraine. Migraine preventive medications currently available in Taiwan can be categorized into s-blockers, antidepressants, calcium channel blockers, anticonvulsants, nonsteroid anti-inflammatory drugs, botulinum toxin type A and miscellaneous medications. Propranolol has the best level of evidence, and is recommended as the first-line medication for migraine prevention. Valproic acid, topiramate, flunarizine and amitriptyline are suggested as the second-line medications. The rest medications are used when the above medications fail. Botulinum toxin type A did not differ from placebo for episodic migraine prevention but its efficacy in chronic migraine is not determined yet. It is not recommended to use migraine preventive medication during pregnancy. For those women with menstrual migraine, nonsteroid anti-inflammatory drug and triptans can be used for prevention during the menstrual period. The levels of evidence for migraine preventive medications in children/adolescents and elderly population are low. The preventive medications should follow the "start low and go slow" doctrine to reach an effective dosage. This can prevent adverse events and increase tolerance. The efficacy of preventive medications can not be evaluated until 3 to 4 weeks after treatment. If the improvement of migraine maintains for 4 to 6 months, physicians can gradually taper down or off the medications. Physicians should notify the patients not to overuse acute medications during migraine prevention treatment.