Prophylactic treatments of migraine.

Prophylactic treatment is mainly intended to reduce the frequency of migrai ne attacks. It is usually proposed to patients who suffer from two or more attacks per month. If should also be considered in patients who suffer from less frequent, but prolonged, disabling attacks with a poor response to ab ortive treatment, and who consider that their quality of life is reduced be tween attacks. Excessive intake of acute medication, more than twice a week is a strong indication for prophylactic treatment In order to obtain a goo d compliance to treatment the patient must be informed of the expected effi cacy of the drugs, and of their most frequent side effects. Thus, the choic e of a prophylactic drug is made together with the patient. Based on the re sults of published controlled trials, the main prophylactic drugs are some betablockers, methysergide, pizotifene, oxetorone, flunarizine, amitriptyli ne, NSAIDs, and sodium valproate. Some less evaluated drugs such as aspirin , DHE, indoramine, verapamil, may be useful. Other substances such as ribof lavin and new antiepileptic dugs are being evaluated. The choice of the dru g to start with depends on several considerations. The first step is to mak e sure that there are no contra indications, and no possible interaction wi th the abortive medications. Then, possible side effects will be taken into account, for example, weight gain is a problem for most young women and pa tients who practice sports may not tolerate betablockers. Associated pathol ogies have to be checked. For example, a hypertensive migraine sufferers ma y benefit from betablockers; in a patient who suffers both from migraine an d tension type headaches or from depression, amitriptyline is the first cho ice drug. The type of migraine should also be considered; for instance, in frequent attacks with aura, aspirin is recommended and betablockers avoided . In most cases, prophylaxis should be given as monotherapy, and it is ofte n necessary to fry successively several drugs before finding the most appro priate one. Doses should be increased gradually, in order to reach the reco mmended daily dose, only if tolerance permits. The treatment efficacy has t o be assessed after 2 or 3 months, during which the patient must keep a hea dache diary. If the drug is judged ineffective, an overuse of symptomatic m edications should be checked, as well as a poor compliance, either of which may be responsible. In case of a successful treatment, it should be contin ued for 6 or 12 months, and then, one should try to taper off the dose in o rder to stop the treatment or at least to find the minimum active dose. Rel axation, biofeedback, stress coping therapies, acupuncture are also suscept ible to be effective in migraine prophylaxis.