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September 26, 2000; 55 (6) Special Article

Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review)

Report of the Quality Standards Subcommittee of the American Academy of Neurology

Stephen D. Silberstein
First published September 26, 2000, DOI: https://doi.org/10.1212/WNL.55.6.754
Stephen D. Silberstein
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Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review)
Report of the Quality Standards Subcommittee of the American Academy of Neurology
Stephen D. Silberstein
Neurology Sep 2000, 55 (6) 754-762; DOI: 10.1212/WNL.55.6.754

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    Table 1.

    Evidence summary for treatment of acute attacks of migraine

    DrugQuality of evidence*Scientific effect*Clinical impression of effect*Adverse effectsRole (by consensus)
    * See Appendix 2 for explanations of quality of evidence, scientific effect, and clinical impression of effect.
    ? = not known; NSAIDs = nonsteroidal anti-inflammatory drugs; ASA = acetylsalicylic acid.
    Triptans (serotonin1B/1D receptor agonists)
    Sumatriptan nasal sprayA++++++OccasionalModerate-to-severe migraine. Useful when nonoral route needed. Less severe migraine when nonopiate medications fail.
    Oral triptansModerate-to-severe migraine. Less severe migraine when nonopiate medications fail.
    NaratriptanA++++Infrequent
    RizatriptanA++++++Occasional
    SumatriptanA++++++Occasional
    ZolmitriptanA++++++Occasional
    Sumatriptan SCA++++++FrequentModerate-to-severe migraine. Useful when nonoral route needed. Less severe migraine when nonopiate medications fail.
    Ergot alkaloids and derivatives
    DHE IVB+++++FrequentLow recurrence.
    DHE SC/IMB+++/+++++OccasionalModerate-to-severe migraine. Less severe migraine when nonopiate medications fail.
    DHE IV plus antiemeticsB++++++FrequentStatus migrainosus. Therapy of choice in emergency department.
    DHE nasal sprayA++++OccasionalModerate-to-severe migraine. Less severe migraine when nonopiate medications fail.
    Low recurrence.
    ErgotamineB+++FrequentConsider for selected patients with moderate-to-severe migraine.
    Ergotamine plus caffeine
    Antiemetics
    Chlorpromazine IM/IVC/B++++Mild to moderateAdjunct therapy. May be choice for acute therapy.
    Metoclopramide IMB++Infrequent to occasionalAdjunct therapy. May be choice for acute therapy.
    PR/IVB++?/++
    Prochlorperazine PR/IMB++++/++OccasionalIM/IV adjunct first-line therapy in emergency department or office; consider PR as adjunct.
    IVB++++++Frequent
    NSAIDs and nonopiate analgesics
    AcetaminophenB0+InfrequentPregnant migraineur.
    Ketorolac IMB+++InfrequentConsider in emergency department.
    Oral NSAIDSOccasionalFirst-line for mild-to-moderate migraine.
    AspirinA++++
    Diclofenac KB++++
    FlurbiprofenB+++
    IbuprofenA++++
    NaproxenB+++
    Naproxen sodiumA++++
    Combination analgesics
    Acetaminophen, aspirin, caffeineA+++++InfrequentFirst-line for migraine.
    Barbiturate hypnotics
    Butalbital, ASA, caffeineC?+++OccasionalOccasional use for moderate-to-severe migraine. Limit use due to risk of overuse.
    Butalbital, ASA, caffeine, codeineB+++++
    Opiate analgesics
    Butorphanol nasal sprayA++++++FrequentModerate to severe migraine; rescue therapy.
    Limit use.
    Opiates—oral combinationsA++++OccasionalModerate to severe migraine; rescue therapy.
    Acetaminophen, codeine combinationsLimit use.
    Opiates—parenteralB++++FrequentReserved for emergency department use or rescue medication.
    Butorphanol IMLimit use.
    Meperidine IM/IV
    Methadone IM
    Other medications
    CorticosteroidsC+++InfrequentRescue therapy in status migrainosus.
    IV plus antiemetics
    Dexamethasone
    Hydrocortisone
    Isometheptene compoundB+++InfrequentMild-to-moderate headache.
    Lidocaine INB++?FrequentUncertain.
    • View popup
    Table 2.

    Acute therapies for migraine

    Group 1*Group 2†Group 3‡Group 4§Group 5¶
    * Proven, pronounced statistical and clinical benefit (at least two double-blind, placebo-controlled studies and clinical impression of effect).
    † Moderate statistical and clinical benefit (one double-blind, placebo-controlled study and clinical impression of effect).
    ‡ Statistically but not proven clinically or clinically but not proven statistically effective (conflicting or in consistent evidence).
    § Proven to be statistically or clinically ineffective (failed efficacy versus placebo).
    Clinical and statistical benefits uknown (insufficient evidence available).
    SpecificAcetaminophen plus codeine POButalbital, aspirin, plus caffeine POAcetaminophen PODexamethaxone IV
    Naratriptan POButalbital, aspirin, caffeine, plus codeine POErgotamine POChlorpromazine IMHydrocortisone IV
    Rizatriptan POButorphanol IMErgotamine plus caffeine POGranisetron IV
    Sumatriptan SC, IN, POChlorpromazine IM, IVMetocloproamide IM, PRLidocraine IV
    Zolmitriptan PODiclofenac K, PO
    DHE SC, IM, IV, INErgotamine plus caffeine plus pentobarbital plus Bellafoline® PO
    DHE IV, plus antiemeticFlurbiprofen, PO
    NonspecificIsometheptene CPD, PO
    Acetaminophen, aspirin, plus caffeine POKetorolac IM
    Aspirin POLidocaine IN
    Butorphanol INMeperidine IM, IV
    Ibuprofen POMethadone IM
    Naproxen sodium POMetoclopramide IV
    Prochlorperazine IVNaproxen PO
    Prochlorperazine IM, PR
    • View popup
    Table 3.

    Preventive therapies for migraine

    TherapiesQuality of evidence*Scientific effect*Clinical impression of effect*Adverse effectsGroup†
    * See Appendix 2 for explanations of quality of evidence, scientific effect, and clinical impression of effect.
    † Scale 1–5; see text for definitions.
    ? = not known; NSAIDs = nonsteroidal anti-inflammatory drugs.
    Antiepileptics
    CarbamazepineB++0Occasional to frequent5
    Divalproex sodium/sodium valproateA++++++Occasional to frequent1
    GabapentinB++++Occasional to frequent2
    TopiramateC?++Occasional to frequent3a
    Antidepressants
    Tricyclic antidepressants
    AmitriptylineA++++++Frequent1
    NortriptylineC?+++Frequent3a
    ProtriptylineC?++Frequent3a
    Doxepin, imipramineC?+Frequent3a
    Selective serotonin reuptake inhibitors
    FluoxetineB++Occasional2
    Fluvoxamine, paroxetine, sertralineC?+Occasional3a
    Monoamine oxidase inhibitors
    PhenelzineC?+++Frequent3b
    Other antidepressants
    Bupropion, mirtazepine, trazodone, venlafaxineC?+Occasional3a
    Beta-blockers
    AtenololB++++Infrequent to occasional2
    MetoprololB+++++Infrequent to occasional2
    NadololB++++Infrequent to occasional2
    PropranololA+++++Infrequent to occasional1
    TimololA++++Infrequent to occasional1
    Calcium channel blockers
    DiltiazemC?0Infrequent to occasional3a
    NimodipineB+++Infrequent to occasional2
    VerapamilB+++Infrequent to occasional2
    NSAIDs
    AspirinB++Infrequent2
    Fenoprofen
    Flurbiprofen
    Mefenamic acid
    IbuprofenC?+Infrequent3a
    KetoprofenB++Infrequent2
    Naproxen/naproxen sodiumB++Infrequent2
    Serotonin antagonists
    CyproheptadineC?+Frequent3a
    MethysergideA++++++Frequent4
    Other
    FeverfewB+++Infrequent2
    MagnesiumB++Infrequent2
    Vitamin B2B+++++Infrequent2
    • View popup
    Table 4.

    Preventive therapies for migraine*

    Group 1†Group 2‡Group 3§Group 4¶Group 5∥
    * Does not include combination products.
    † Medium to high efficacy, good strength of evidence, and mild-to-moderate side effects.
    ‡ Lower efficacy than those listed in first column, or limited strength of evidence, and mild-to-moderate side effects.
    § Clinically efficacious based on consensus and clinical experience, but no scientific evidence of efficacy.
    ¶ Medium to high efficacy, good strength of evidence, but with side effect concerns.
    ∥ Evidence indicating no efficacy over placebo.
    AmitriptylineB-blockersA: AntidepressantsMethysergideAcebutolol
    Divalproex sodiumAtenolol/metoprolol/nadololDoxepineCarbamazepine
    Propranolol/timololFluvoxamineClomipramine, clonazepam
    Ca-blockersImipramineClonidine
    Nimodipine/verapamilMirtazepineIndomethacin
    NortriptylineNicardipine
    NSAIDsParoxetineNifedipine
    Aspirin/fenoprofen/flurbiprofenProtriptylinePindolol
    KetoprofenSertraline trazodone
    Mefenamic acidVenlafaxine
    NeproxenCyproheptadine diltiazem
    Naproxen sodiumIbuprofen
    Fluoxetine (racemic)Tiagabine
    GabapentineTopiramate
    OtherB: (side effect concerns)
    FeverfewMethylergonovine (methylergometrine)
    Magnesium vitamin B2Phenelzine

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