medications should not be the first treatment for migraines. And doctors
shouldn't routinely order brain scans for patients with these debilitating
headaches, according to new guidelines.
Taking a stand on common
but often unnecessary or potentially risky tests and treatments for migraine,
the American Headache Society published new recommendations in the
November-December issue of the journal Headache.
"Our aim is to
encourage doctors and patients to think carefully about medical care that can
be harmful or unnecessary," said Dr Elizabeth Loder, president of the
American Headache Society. "We didn't approach this with cost uppermost in
mind. The goal is to help address the problems of low-value care."
Opioid painkillers, such as
OxyContin and Vicodin, and the barbiturate butalbital pose serious long-term
risks, the society said.
"The effectiveness of
opioids is not the question," explained Loder, chief of the division of
headache and pain in the neurology department at Brigham and Women's Hospital
in Boston. "The problem is that even if they are effective in a single
attack, for many people migraine is a chronic disorder that they will have for
The risk of dependency
associated with these drugs is evidenced by the growing epidemic of
prescription painkiller abuse in the United States. Nearly three out of four
prescription drug overdoses are caused by opioid painkillers, according to the
US Centres for Disease Control and Prevention.
"This ends up being a
second problem patients have," Loder noted.
Using too much of these
pain medications can also lead to a condition called medication overuse
headache, said another expert.
"There is a lot of
research that opioids actually increase the sensitivity to pain in the head,"
said Dr Rebecca Erwin Wells, assistant professor of neurology at Wake Forest
Baptist Medical Centre in Winston-Salem, North Carolina. Medication overuse headaches are
difficult to treat, Wells added.
MRI better value and safer
In addition, the guidelines
indicate that brain scan studies should not be performed on patients with
stable headaches that meet criteria for migraine. And CT scans should not be
used in a non-emergency situation as a diagnostic tool for headache patients
when MRI is available.
"MRI can diagnose more
conditions that may cause headache that CT scans can miss," Loder explained.
Also, unlike CT scans, MRIs
use powerful magnets and do not expose patients to radiation. "MRI is
better value and safer," Loder concluded.
The headache specialists
also said that surgery targeting migraine trigger points is still experimental
and not recommended outside of a clinical trial.
"We lack sufficient
evidence to say the benefits of surgery outweigh the potential harms or that it
is even helpful," Loder cautioned. Before new drugs can be approved for
use, they must go through rigorous testing that meets a certain standard, she
noted, "and the standard for surgical interventions that are irreversible
should not be lower."
Finally, prolonged or
frequent use of over-the-counter pain medications for headache is also unwise,
the guidelines state. People shouldn't take these drugs more than twice a week,
Loder agreed. "It's
not good for the kidneys, liver or stomach to be taking these medications on a
daily basis," Loder said. "There are a lot of strategies that can
work that are better than just grabbing handfuls of Motrin."
So what does work for most
migraine sufferers? Triptans are a family of drugs used to stop migraines once
they start, Loder said. And preventive therapies such as biofeedback can be
used on a regular basis by people who experience frequent migraines, she added.
Biofeedback is a technique that people can learn to use to help change how
their body responds to physical symptoms.
Getting enough sleep and
not skipping meals can also help keep migraine pain at bay, she suggested.
Migraine treatment and
perceptions of the condition itself have changed dramatically over the years.
Scientists now believe migraine has a genetic link and that the disorder
involves brain chemistry and nerve pathways.
"We understand a lot
more about different kinds of headache and have specific treatments that
work," Loder said.
It's estimated that 12% of
Americans get migraine headaches, three times as many women as men.
The US National Institute
of Neurological Disorders and Stroke provides more information on migraine.