Most of us prescribe polytherapy for prevention for
intractable migraine and may have our own favorite combos. And yet,
there is an amazing dearth of studies to guide such a common
clinical problem.
When should the use of combined treatment be considered and which
combinations? We think that combined treatment should be prescribed
only after the patient has not responded to two consecutive adequate
trials (therapeutic doses for at least 6 weeks) of two of the "major"
preventatives (especially beta-blockers and neuromodulators), so
long as that tolerability is not a problem. Regarding potential
combinations, a beta-blocker together with Amitriptyline at night
is an adequate option for those migraine patients experiencing
interictal, tension-type headaches. For "purer" migraine patients
and to maximize compliance, we would recommend a beta-blocker in a
morning dose (e.g., nadolol, atenolol, or long-acting propranolol)
plus a neuromodulator at night (topiramate or extended release
valproate). In refractory cases with tolerability problems on
these combinations, other usually forgotten options, such as
riboflavin or magnesium, at adequate doses, could also be tried.
Lamotrigine is one further combination option in case relevant
auras still remain. In summary, with no current ideal drug for
migraine prevention and with nothing very promising on the horizon,
the combination of thee preventatives is an option to explore in
clinical practice for those patients who have shown no clear effect
of appropriate monotherapy. It would be very recommendable to
design in the future controlled clinical trials testing these
potential advantages of combination preventive therapy in resistant
patients. The same is true for symptomatic treatment, where at
least 20% of patients do not respond either to triptans of NSAIDs
separately and some recent, preliminary trials (and daily experience)
suggest that these refractory patients can benefit from their
combination.
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