Evidence-based guidelines 2012 - migraine treatment

Hi All,

Updated evidence-based guidelines have been released (24 April 2012) for health professionals in the US covering the pharmacological treatment for migraine prevention in adults. Note these sorts of guidelines are released for many medical conditions and guide health professionals on choosing the best medications according to the evidence.

You’ll notice here that drugs like Effexor (venlafaxine) are at “Level B” alongside amitriptyline while neural stabilisers and some beta blockers remain at “Level A”. Still no solid evidence for SSRIs.

Full article here with introduction and methods used:

national_guidlines2012.pdf (420.2 KB)

(Edited by @turnitaround : old broken link http://www.mvertigo.org/articles/national_guidlines2012.pdf)

Scott 8)

Thanks for posting. Guess that’d explain why my neuro told me yesterday that if the Topamax doesn’t work, I can try Lyrica, but after that he’s out of ideas and he’ll need to refer me to another neuro. He’s VERY dependent on what studies have shown/proved in what he’ll give me to try. Hence, no SSRI’s. Only the Level A’s for him, it seems. (Oh, he did let me try Effexor - on my request, so I guess I did make him branch out a smidge… :wink:

[Totally unrelated to your article: I also realized he’s really not on board with the whole idea of vestibular migraines, either. He’s still thinking it must be some sort of basilar migraine (even though he’s admitted it doesn’t really fit). Anyhow, I’ll wait and see the hormone doc once more (maybe she’ll let me try out some of the other SSRIs), but I guess for my referral, I’ll ask to see the guy at Emory. A bit of a hike (about an hour and a half from here) and his evals scare me, but if he’s a pro, I suppose I’m up for it!]

My doc is very study dependent as well–he seen anything that convinces him SSRI’s are the way to go, yet. That being said, he said there were very many (10+) medications that he had found were effective, so I have hope that we’ll hit on one that works.

If not, I figure I’ll try to get in with Hain in Chicago and try the Effexor. Or maybe at that point my doc will be willing to prescribe it.

Topamax is next up for me unless I stabalize on Nortriptyline soon. I’m a little intimidated by Topamax–it seems to have a lot more side effets.

Jamie, I don’t know if this sets your mind at ease about the topa or not… I actually haven’t had too many side effects. I started really low (12.5 the 1st week) and am going really slow, as everyone as recommended. That said, I’m currently “stuck” at 25, 3.5 weeks in, because the only major side effect I’ve had is fatigue. When I kicked it up to 37.5 this weekend, it was tolerable, but when I tried doing that at work this week, I was sure I’d keel over at my desk. :wink: Went back down to 25. Will try to up it again this weekend to get pas the fatigue. I think it really just depends on the person like any other med.

My issue is that the vast majority of what my doc has had me try are anticonvulsants as those are the ones on his tried and true list. I’m beginning to wonder if it’s just the wrong class of drugs for me. I’ll give the topa a fair shot (if I can), but I think a little more flexibility than he’s got to offer may be in order. (I can’t do the beta-blockers as they make my arrhythmia worse, and I’m already on Verapamil…)

Maybe your doc will let you try Effexor without you having to go to Hain… It is a class B drug, after all. :wink:

Thanks Erika, that does make me feel a little bit better. I am pretty tolerant of drugs that are supposed to make you tired, so if that ends up being the one side-effect i see I’d be thriled.

Nortriptyline is not on here. Is it safe to say it falls under Amitriptyline…?

I thought they were supposed to be similiar. But from what I have read they have the same foundation, but opposite of what they hit?
Anyone know about this.?


Well that’s funny…I am on 2 drugs that fall into the “level B” category (probably work). I know these are just guidelines that medical professionals can use to determine what they will prescribe patients. Guess if you doc follows evidence based practice then you will be trialing level A drugs first. Which actually makes sense, however it’s obvious that further research needs to be done on other meds down the line.

Nortriptyline is a TCA (tricyclic antidepressant)as is Amitriptyline.
I’m not sure of the exact pharmacology but I’m on Dosulepin (TCA) which for me is more effective and with fewer side effects than Amitriptyline.

This article doesn’t address vertigo or dizziness at all…only the migraine headache component

Nortriptyline did nothing for me. Amitriptyline improves things greatly. I also am tolerant of medications that cause sleepiness, so I can take a lot of amitrip in addition to a long acting benzo (chlordiazepoxide) every night. Effexor in the morning with my coffee.

— Begin quote from “jennP”

This article doesn’t address vertigo or dizziness at all…only the migraine headache component

— End quote

It doesn’t address the vertigo or dizziness directly, but sometimes doctors treat the dizziness/vertigo simply by treating the migraine. Headache is just another symptom of migraine like the vertio/dizziness is. Supressing the migraine should result in a reduction of all migraine symptoms including both headache and vertigo, though not all suppression medications seem to work equally well on all symptoms.

For example, I didn’t even get headaches at all. Rocking vertigo/instability was my main symptom. But the doctors directly treated me for migraines anyway and supressing the migraines is what has gotten me better.

Interesting that antiepleptic drugs ended up in the first and last column.

That is just a subheader. Specifically, the antiepileptic drugs Divalproex sodium, Sodium valproate and Topiramate are in the first column (established efficacy in 2 or more Class 1 trials) while the antiepileptic drug Lamotrigine is in the last column (established as not effective).

The antiepileptic drug Carbamazepine in classified as a Level C (possibly effective), and the antiepileptic drug Gabapentin is classified as Level U (Inadequate or conflicting data). So antiepileptic drugs are found in almost every colum of the chart.

I am not sure if you are still on this website, but if you are, I am interested in knowing more about your med situation. I am currently on 25 mg a day of chlordiazepoxide, and my doctor wants me to add amitriptyline. I also seem fine with medications that cause drowsiness. Did you experience any side effects when you started the amitriptyline? My doctor wants to start me on 5 mg for 4 days then increase to 10 mg. Thanks!

Hi Jess, Sorry this isn’t from the old chain, but I thought you might be interested in this conversation involving Erika from a while back regarding Topamax (pasted below), which I guess she too tried but stopped because she felt very strange at the beginning - I have been on and off of it because of side effects (but now I’m determined to stick it out at least for a few months at 50mg once taken at night with maybe some nortriptyline to soften the side effects that I notice, to see if it helps). I can’t really find any other meds on here that have helped people have such high success rates as Topamax. I just can’t not try to cope on it to see if it levels out after a while. Hope we feel better soon… xx