Headache Drugs Logo
Home | About Dr. Robbins | Archived Articles | Headache Books | Topic Index  

Back to List


Bending the Rule of Monotherapy for Migraine Prevention?
Randolph W. Evans, MD; Julio Pascual MD; et al.
Posted: August 2005  
Headache 2005;45:748-750

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.