Prevention of migraine

Drugs for the prevention of migraine have been shown to reduce its frequency, improve migraine specific quality of life,1 and reduce the overall costs of migraine related care.2 3 Unfortunately, however, they are underused. In a recent population based study, fewer than 20% of people deemed eligible for preventive treatment had received a preventive drug.4

In clinical practice, the approach to patients who need preventive drugs goes beyond simply writing a prescription. Patients should also be given advice on identifying and managing triggers, making lifestyle modifications, and using biobehavioural techniques (such as relaxation and cognitive behavioural therapy) when appropriate and on optimising the acute treatment of attacks.5 However, the comparative efficacy of these strategies has not been systematically evaluated⇓.

In the linked randomised placebo controlled trial (doi:10.1136/bmj.c4871), Holroyd and colleagues randomised 232 people who remained disabled, despite an optimised 30 day run-in of acute treatment, to the addition of one of four preventive treatments.6 These treatments were a β blocker (propranolol up to 240 mg or nadalol up to 120 mg), placebo, behavioural migraine management (BMM) plus placebo, or BMM plus β blocker. BMM included education, trigger management, relaxation, pain management, and optional biofeedback or stress management. Treatment was blinded only for …