Current therapy options from low to high confidence for prevention are listed in Table I.
Amitriptyline (1 mg/kg/d) combined with cognitive behavioral therapy (CBT) carries the highest confidence of efficacy. This combination has been shown to decrease frequency of migraine or headache days and headache frequency by at least 50%. However, this difference has not been shown in amitriptyline in combination with headache education alone.
In a randomized trial published in 2013, researchers assessed amitriptyline as well as CBT for chronic migraine compared to amitriptyline plus headache education in children and adolescents. The primary endpoint was headache days and the secondary was PedMIDAS score at 20 weeks. Clinical significance was defined as a > 50% reduction in headache days and PedMIDAS score < 20 points. Headache days were reduced significantly by 11.5 days for the amitriptyline plus CBT group vs 6.8 days in the headache education plus amitriptyline group. Scores of the PedMIDAS decreased by 52.7 points versus 38.6 points which was significant in favor of amitriptyline plus CBT…
The only category that holds medication in high confidence is the outcome of being pain-free at 2 hours, including sumatriptan/naproxen oral tablet 10/60 mg, 30/180 mg, 85/500 mg, and zolmitriptan nasal spray 5 mg.1
A trial was published in 2012 comparing the efficacy and safety of all three doses of sumatriptan/naproxen combination therapy. This study included patients ages 12 to 17 years with two to eight migraine attacks per month for 6 months that typically lasted more than 3 hours when untreated. The primary endpoint was being pain-free at 2 hours. Rates of pain-free status were significantly higher in all three treatment groups compared to placebo. A post-hoc analysis found no differences among the three dosing regimens. Two-hour photophobia-free and phonophobia-free status were significant in the 85/500 mg group compared to placebo. Additionally, pain-free status was sustained to 24 hours in the 85/500 mg group.6 In the triptan class, while it is safe to take these medications during the aura preceding a migraine, it may be more effective when taken at the start of pain.1 Table II summarizes the acute treatment options recommended in the new guidelines. Generally, triptans are avoided as first-line options until non-prescription options (ie, acetaminophen, ibuprofen) have failed. For consideration of triptans, the safety profile should be weighed against the clinical benefits of use.
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