Problematic recommendations in ANN's guidelines on drug prevention of migraine.
Peer CarstenTfelt-Hansen, Consultant
Published August 21, 2012
According to the recent AAN update guideline, a drug can be recommended as possibly effective for migraine prevention if it had demonstrated efficacy in one Class II study. [1]. Eight drugs are recommended as possibly effective [1]; and there are several drugs for which I would question the evidence. Due to space limitations, I will mention only one example. In the 2000 AAN Practice Parameter, [2] pindolol was in group 5 (evidence indicating no efficacy over placebo).This was based on two negative randomized, placebo-controlled trials. [3] It is unclear to me how pindolol is now listed in level C as possible effective. A possible explanation could be a re-analysis of an old comparative study of pindolol, clonidine and carbamazepine. [4] In a technical report [5] from1999 re-analyzing this study, [4] pindolol was reportedly superior to carbamazepine. However, this study was an open study and not a randomized, double-blind trial. [4] Pindolol has partial agonist activity [3] and this property is generally not compatible with preventive effect in migraine [3].
1.Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline
update: Pharmacologic treatment for episodic migraine prevention in adults. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012;78: 1337-1345.
2.Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000;55: 754-762.
3.Tfelt-Hansen P, Rolan P. b-Adrenoceptor blocking drugs in migraine prophylaxis. In:
Olesen J,Goadsby PJ, Ramadan NM, Tfelt-Hansen P, Welch KMA, eds. The
Headaches. 3rd Eds..Philadelphia York: Lippincott Williams & Wilkins 2006:519-528.
4.Anthony M, Lance JW, Sommerville B. A comparative trial of prindolol, clonidine and carbamazepine in the interval therapy of migraine. Med J Aust 1972; 1: 1343-1346.
5.Gray RN, Goslin RE, McCrory DC,et al. Drug Treatment for the Prevention of Migraine Headache. Technical Reviews, No. 2.3. Center for Clinical Health Policy Research, Duke University. Rockville (MD): Agency for Health Care Policy and Research (US): February 1999. Available from:
http://www.ncbi.nlm.nih.gov/books/NBK45457/ (Assessed July 25 2012).
For disclosures, contact the editorial office at journal@neurology.org.
According to the recent AAN update guideline, a drug can be recommended as possibly effective for migraine prevention if it had demonstrated efficacy in one Class II study. [1]. Eight drugs are recommended as possibly effective [1]; and there are several drugs for which I would question the evidence. Due to space limitations, I will mention only one example. In the 2000 AAN Practice Parameter, [2] pindolol was in group 5 (evidence indicating no efficacy over placebo).This was based on two negative randomized, placebo-controlled trials. [3] It is unclear to me how pindolol is now listed in level C as possible effective. A possible explanation could be a re-analysis of an old comparative study of pindolol, clonidine and carbamazepine. [4] In a technical report [5] from1999 re-analyzing this study, [4] pindolol was reportedly superior to carbamazepine. However, this study was an open study and not a randomized, double-blind trial. [4] Pindolol has partial agonist activity [3] and this property is generally not compatible with preventive effect in migraine [3].
1.Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012;78: 1337-1345.
2.Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000;55: 754-762.
3.Tfelt-Hansen P, Rolan P. b-Adrenoceptor blocking drugs in migraine prophylaxis. In: Olesen J,Goadsby PJ, Ramadan NM, Tfelt-Hansen P, Welch KMA, eds. The Headaches. 3rd Eds..Philadelphia York: Lippincott Williams & Wilkins 2006:519-528.
4.Anthony M, Lance JW, Sommerville B. A comparative trial of prindolol, clonidine and carbamazepine in the interval therapy of migraine. Med J Aust 1972; 1: 1343-1346.
5.Gray RN, Goslin RE, McCrory DC,et al. Drug Treatment for the Prevention of Migraine Headache. Technical Reviews, No. 2.3. Center for Clinical Health Policy Research, Duke University. Rockville (MD): Agency for Health Care Policy and Research (US): February 1999. Available from: http://www.ncbi.nlm.nih.gov/books/NBK45457/ (Assessed July 25 2012).
For disclosures, contact the editorial office at journal@neurology.org.