Migraine Prevention Therapy: How long is “long enough”?
You’ve had migraine for years, but until recently it was never really that much of a problem. A bad headache every six months or so since since college years…at times bad enough to demand bed rest in a dark room. But not really all that often or that much of a problem.
Then you went and had a baby, and as breast-feeding was winding down you began to experience not just more frequent versions of your same old migraine episodes but also a near-daily headache that often builds to become almost as bad as your “usual migraines”.
You go to see your doctor, and he tells you that you need to start a medication for migraine prevention. How long will I need to take it? you ask. As long as it takes, he answers. When you get home from the appointment you do what you can to find out about this prevention medication and learn that it can cause weight loss (sounds good), some kind of weird tingling, kidney stones (ugh), and (really ugh) problems thinking and speaking. What the hell? you think.
But you start the medication, put up with some side effects and hang in there. After a year has passed you tell your doctor at a follow-up appointment that you have been essentially headache-free for months. Can I stop the medication? you ask.
A very, very good question. Many headache subspecialists who are expert clinicians will tell you what boils down to “Don’t kick a sleeping dog”, with the implication seeming to be that you should remain on this medication…forever. Your husband is just happy that you’re not having headaches (and thinner). God knows, the pharmaceutical company that owns the medication obviously has no incentive to encourage you to stop therapy. What should you do?
As a migraineur myself, as a clinical neuroscientist who has, along with many others, assisted in the clinical development of every almost every new therapy for migraine since injectable sumatriptan in the late 1980s and, ultimately, as a Very Bad Patient who would prefer not to take any medication on a long-term basis, a portion of my research understandably has been devoted to answering the question: when it comes to migraine prevention therapy, how long is long enough?
As my colleagues and I were developing divalproex sodium (Depakote) for migraine prevention many years ago, my team and I conducted a study to see what would happen if after 2 months of migraine eradication we tried discontinuing Depakote. The results were not so good. A majority of the patients who had responded so well to Depakote almost immediately relapsed to frequent migraine and required a restart of prevention therapy.
On the other hand, Dr. Robert Kaniecki, a respected colleague of mine possessed of both clinical expertise and excellent common sense, carefully looked at how his migraine patients fared after 1 year of successful treatment with one of the older prophylactic medications and found that most were able to stop their prevention medication without experiencing any consequent worsening of their migraine burdens.
My research team and I subsequently studied onabotulinumtoxinA (BotoxA) in an investigation entitled “Can Botox be Stopped?” and found that when patients reached a certain point of stable clinical improvement, the vast majority were able to stop treatment and continued to do well for up to 5 years of follow-up.
So what can we glean from this and other relevant research?
There appear to be relatively few patients with migraine who require chronic “forever” prevention therapy.
While it’s entirely possible that the optimal duration of prevention therapy varies from migraineur to migraineur and from therapy to therapy, in general it appears that at least 6 months of migraine stabilization (and perhaps as much as 1 year) may be required before the prevention therapy being used can be stopped without a significant likelihood of rapid relapse.
There conceivably may exist some prevention therapies that cannot be stopped without incurring a high risk of early relapse.
There conceivably may exist some prevention therapies that will be effective for an extended time but then lose their effectiveness or, even worse, begin to promote headache.
Even without treatment, migraine is a variable beast, activating and deactivating on its own and without any obvious external provocation. Coupling this with the unproven but definitely hypothetical possibility that continuing a prevention treatment indefinitely might eventually come to be detrimental, be persistent in asking your physician, “How long do I need to be on this medication?”