Doctors' Groups Issue Migraine Guidelines

First set of recommendations from primary care physicians

TUESDAY, Nov. 19, 2002 (HealthDayNews) -- The nation's two largest groups of primary care physicians are issuing their first set of guidelines for the prevention and treatment of migraines.

The guidelines, formulated by the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) and the American Academy of Family Physicians (AAFP) and directed to physicians, recommend aspirin or ibuprofen as the first line of therapy.

Normally, migraine guidelines are put out by neurologists. When the ACP-ASIM conducted a survey in the mid 1990s of the topics its members would like to see guidelines on, headaches topped the list.

"It's a very common complaint in primary care," says Dr. Vincenza Snow, senior medical associate in ACP-ASIM's department of scientific policy. Primary care is where most migraine sufferers first encounter the health care system.

According to the new guidelines, published in today's issue of Annals of Internal Medicine, 28 million Americans suffer from these severe, recurring headaches, representing 18 percent of all women and 6.5 percent of all men. About half of these people have not been diagnosed or remain undertreated.

The guidelines were based on an extensive review of the existing medical literature by representatives from the fields of emergency medicine, internal medicine, neurology and other disciplines.

"These guidelines are really evidence-based, which means they were really crafted only after a really rigorous review of the medical literature," says Dr. Eric Wall, a family physician from Portland, Ore., who represented the American Academy of Family Physicians in the development of the guidelines. "We really had to hammer it out."

The guidelines may be more conservative than many people would like, Wall concedes, but this is only a reflection of the available literature.

"Some people will say it doesn't go far enough, that it doesn't address new treatments, new therapies," he says. "It is fairly conservative in its recommendations but, unfortunately, that really reflects the state of the science right now."

Conservative or not, here is what the multidisciplinary team has recommended:

  • The first line of therapy should be nonsteroidal anti-inflammatory drugs (NSAIDS), with the most reliable appearing to be the over-the-counter stalwarts aspirin and ibuprofen. There is no proof that acetaminophen on its own is effective for migraines. "People need to be taking the right kind of over-the-counter medications," says Snow. "Not all of them are good for migraine."
  • If these drugs don't work, patients and physicians should move on to drugs specifically developed for migraines, such as triptans or DHE nasal spray.
  • If patients have nausea or vomiting, non-oral remedies should be tried first. Nausea and vomiting should also be treated directly.
  • People who have repeated migraines should be evaluated for possible preventive therapy. Generally, good candidates for preventive measures are patients who have two or more migraines that last three or more days each month; fail to respond to migraine treatment; use medication more than twice a week; or have "uncommon" migraine conditions such as aura (visual sensations).
  • Migraine sufferers should be actively involved in formulating their own treatment plan, the guidelines says. And they should chart their headaches and identify and avoid triggers such as alcohol, chocolate, caffeine, foods containing additives (MSG, tyramine or nitrates), sleep loss, stress and perfumes.

What To Do

For more on migraines, visit the JAMA Migraine Information Center or the National Library of Medicine.

SOURCES: Eric Wall, M.D., M.P.H., American Academy of Family Physicians, Portland, Ore.; Vincenza Snow, M.D., senior medical associate, department of scientific policy, American College of Physicians-American Society of Internal Medicine, Philadelphia; Nov. 19, 2002, Annals of Internal Medicine
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