Gherpelli, José Luiz Dias

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Cadernos Espinosanos (E-Journal)

249REV. HOSP. CLÍN. FAC. MED. S. PAULO 57(6):249-250, 2002NOVEMBER-DECEMBEREDITORIALNEW MIGRAINE PROPHYLACTIC DRUG OPTIONSJosé Luiz Dias GherpelliRHCFAP/3101GHERPELLI JLD - New migraine prophylactic drug options. Rev. Hosp. Clín. Fac. Med. S. Paulo 57(6):249-250, 2002.The review article published in thisissue, concerning new options for pre-ventive drug treatment of migraine,deals with a subject that always drawsthe attention of both general practi-tioners and neurologists because of thehigh frequency with which they areconfronted with doubts related to treat-ment in everyday practice. Severaldrugs are reported to be useful andconsequently are used for both acuteand preventive treatment of migraineattacks, with a wide range of efficacybetween them that probably arises fromdifferent individual responses, whicharise from different pathophysiologicfactors that may be involved in eachcase. Several drugs have been testedfor their therapeutic efficacy in well-conducted, double-blind, placebo-con-trolled clinical trials. Nevertheless, pa-tients often have a disappointing clini-cal response. From time to time, re-view articles are published on the sub-ject1,2, and although they suggest thatseveral drugs are efficient in decreas-ing migraine frequency and/or inten-sity, they also show that we are far fromidentifying the ideal drug. This failureis most certainly related to our poorunderstanding of the basic diseasemechanisms. Perhaps it would be moreappropriate to address migraine as agroup of closely related entities, sincethere are different types of migraine(with differences in the intensity, trig-gering, and associated factors, pres-ence or absence of the different typesof aura, etc.), probably with differentpathophysiologic etiologies.Even the mechanisms of action ofthe various drugs that are used in pre-ventive migraine treatment are notfully understood.The placebo effect is particularlyhigh, not only in preventive therapy,but also in the acute phase, rangingfrom 20% to 70%, according to reportsin the literature4. This fact only addsto the difficulties in studying drug ef-ficacy in a disease in which psycho-somatic or other environmental factorsseem to play such an important role inits symptomatic expression. Therefore,even studies that adhere to the strictrules of scientific research must be in-terpreted with caution when they testa new drug option. Other investigatorsmust retest these drugs before they canbe accepted as really useful. The re-view article reports on the efficacy ofFrom the Child and Adolescent HeadacheClinic of the Department of Neurology,Hospital das Clínicas, Faculty of Medicine,University of São Paulo.several drugs that have been testedand still have not been widely used inpreventive migraine therapy.Reports on the efficacy of ribofla-vin and magnesium salts were origi-nally published some years ago. Theseare low cost-therapies and ideallyshould be studied further to make surethat their efficacy is reliable, and theiradverse-effect rate is low enough to al-low them to be incorporated into ourprescriptions.The efficacy of antiepileptic drugsin preventive migraine therapy is along story that waxes and wanes overthe time. Several of the traditionaldrugs, such as phenobarbital, pheny-toin, carbamazepine, and more re-cently, divalproate, were or are stillused, with efficacy reported eventuallyfor all of them over the years, but sel-dom proven, except regardingdivalproate. The new antiepilepticdrugs—gabapentin, topiramate,zonisamide, tiagabine, andlevetiracetam, which were reviewed inthe article in this issue—have onlyscant data on their efficacy (most of thereferences cited were published as ab-stracts). Lamotrigine, another recentlymarketed antiepileptic drug, has alsobeen tested, and it proved ineffectivewith migraines3. On the other hand, all250REV. HOSP. CLÍN. FAC. MED. S. PAULO 57(6):249-250, 2002 NOVEMBER-DECEMBERthese newer drugs are much more ex-pensive than the traditional drugs usednowadays, a problem that is particu-larly important in developing coun-tries. The high-cost problem also willlimit the use of botulinum toxin.Concerning the other drugs,montelukast and lisinopril, their effi-cacy and place in migraine treatmentis welcome if proven over the years,because positive results followingtreatment with these drugs will alsoadd to our understanding of the basicpathophysiologic mechanisms of thedisease.REFERENCES1. ADELMAN JU, BROD A, VON SEGGERN RL et al. - Migrainepreventive medications: a reappraisal. Cephalalgia 1998, 18:605-11.2. SILBERSTEIN SD - Preventive treatment of migraine: an overview.Cephalalgia 1997, 17: 67-72.3. STEINER TJ, FINDLEY LJ & YUEN AW - Lamotrigine vs. placeboin the prophylaxis of migraine with and without aura.Cephalalgia 1997, 17: 109-12.4. TFELT-HANSEN P, BOUSSER M-G, SOLOMON S et al. -Guidelines for controlled trials of drugs in migraine. In: TheIHS Member’s Handbook 2000. Stockholm: Scandinavian UnivPress, 1999, p. 111-33.See related article on page 293.

New Migraine Prophylactic Drug Options

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New Migraine Prophylactic Drug Options

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