University of Calgary and the Hotchkiss Brain Institute, Calgary, AB, Canada.
Can J Neurol Sci. 2012 Mar;39(2 Suppl 2):S1-59.
The primary objective of this guideline is to assist the practitioner in choosing an appropriate prophylactic medication for an individual with migraine, based on current evidence in the medical literature and expert consensus. This guideline is focused on patients with episodic migraine (headache on ≤ 14 days a month).
Through a comprehensive search strategy, randomized, double blind, controlled trials of drug treatments for migraine prophylaxis and relevant Cochrane reviews were identified. Studies were graded according to criteria developed by the US Preventive Services Task Force. Recommendations were graded according to the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group. In addition, a general literature review and expert consensus were used for aspects of prophylactic therapy for which randomized controlled trials are not available.
Prophylactic drug choice should be based on evidence for efficacy, side-effect profile, migraine clinical features, and co-existing disorders. Based on our review, 11 prophylactic drugs received a strong recommendation for use (topiramate, propranolol, nadolol, metoprolol, amitriptyline, gabapentin, candesartan, butterbur, riboflavin, coenzyme Q10, and magnesium citrate) and 6 received a weak recommendation (divalproex sodium, flunarizine, pizotifen, venlafaxine, verapamil, and lisinopril). Quality of evidence for different medications varied from high to low. Prophylactic treatment strategies were developed to assist the practitioner in selecting a prophylactic drug for specific clinical situations. These strategies included: first time strategies for patients who have not had prophylaxis before (a beta-blocker and a tricyclic strategy), low side effect strategies (including both drug and herbal/vitamin/mineral strategies), a strategy for patients with high body mass index, strategies for patients with co-existent hypertension or with co-existent depression and /or anxiety, and additional monotherapy drug strategies for patients who have failed previous prophylactic trials. Further strategies included a refractory migraine strategy and strategies for prophylaxis during pregnancy and lactation.
There is good evidence from randomized controlled trials for use of a number of different prophylactic medications in patients with migraine. Medication choice for an individual patient requires careful consideration of patient clinical features.
本指南的主要目的是根据医学文献中的现有证据和专家共识，帮助医生为偏头痛患者选择合适的预防药物。本指南侧重于发作性偏头痛（每月头痛发作≤14 天）患者。
通过全面的搜索策略，确定了偏头痛预防药物治疗的随机、双盲、对照试验和相关的 Cochrane 综述。根据美国预防服务工作组制定的标准对研究进行分级。根据推荐评估、制定与评估（GRADE）工作组的原则对建议进行分级。此外，对于没有随机对照试验的预防性治疗方面，还使用了一般文献综述和专家共识。
预防性药物选择应基于疗效、副作用谱、偏头痛临床特征和并存疾病的证据。根据我们的综述，有 11 种预防药物得到了强烈推荐（托吡酯、普萘洛尔、纳多洛尔、美托洛尔、阿米替林、加巴喷丁、坎地沙坦、小白菊、核黄素、辅酶 Q10 和柠檬酸镁），6 种药物得到了弱推荐（丙戊酸钠、氟桂利嗪、哌迷清、文拉法辛、维拉帕米和赖诺普利）。不同药物的证据质量从高到低不等。制定了预防治疗策略，以帮助医生在特定临床情况下选择预防药物。这些策略包括：以前未接受过预防治疗的患者的首次治疗策略（β受体阻滞剂和三环类药物策略）、低副作用策略（包括药物和草药/维生素/矿物质策略）、体重指数高的患者策略、伴有高血压或同时伴有抑郁和/或焦虑的患者策略，以及以前预防性试验失败的患者的额外单一药物治疗策略。其他策略包括难治性偏头痛策略和妊娠及哺乳期预防策略。
有大量随机对照试验证据支持在偏头痛患者中使用多种不同的预防药物。个体患者的药物选择需要仔细考虑患者的临床特征。
