Evidence-Based Medicine for Student Health Services
Robert J. Flaherty, MD
Swingle Student Health Service
Montana State University
Bozeman, MT 59717
 
Headache 
  
Etiology Monitoring
Epidemiology Prognosis
Diagnosis Prevention
Treatment Patient Education
  
General Information
    
EBM for Student Health   
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Specific Conditions/Diseases 
 
   
     
 		    
Etiology  
No evidence is cited.  
   
Epidemiology  
No evidence is cited.  
   
Diagnosis  
Migraine 
Clinical Diagnosis 
Guidelines for the diagnosis and treatment of migraine headache have been developed by the Canadian Headache Society:    (Most recommendations are supported by high quality evidence.)  Laboratory/X-ray Diagnosis 
Guidelines for the diagnosis and treatment of migraine headache have been developed by the Canadian Headache Society:  
  • Investigations such as EEG, CT, MRI, and lumbar puncture are not recommended in the routine evaluation of patients with headache but may be useful where some atypical symptoms are present.
 (Most recommendations are supported by high quality evidence.)  Other Headaches 
Clinical Diagnosis 
No evidence is cited. 
   
Laboratory/X-ray Diagnosis 
No evidence is cited. 
    
Treatment   
Migraine 
Pharmacologic Therapy    
Guidelines for the diagnosis and treatment of migraine headache have been developed by the Canadian Headache Society:  
  • Drug therapy is indicated if the headaches threaten to disrupt the patient's ability to function normally. A range of medications is considered according to the severity of the attack. Choice is often individual and idiosyncratic. (See Guideline for details)
  • Medication for mild attacks supported by evidence include: acetylsalicylic acid, ibuprofen and naproxen.
  • For moderate attacks, NSAIDs are useful, also: sumatriptan (orally or subcutaneously administered) and dihydroergotamine (DHE) (subcutaneously, IM or IV).
  • For severe attacks, treatments are mostly IV and include: DHE, sumatriptan and chlorpromazine.
  • Few prophylactic medications have been subjected to adequate clinical trial. The aim is to use the least amount of the medication with the fewest side effects to gain control of the symptoms until the treatment can be stopped. Beta blockers (atenolol, metoprolol, nadolol and propranolol), calcium channel blockers (flunarizine and verapamil), serotonin receptor antagonists, methysergide are amongst the drugs considered for this kind of management. (See Guideline for details)
 (Most recommendations are supported by high quality evidence.)  The relative effectiveness of several medications for acute migraine headache are (most to least effective): subcutaneous sumatriptan 6 mg, oral sumatriptan 100-200 mg, 4% intranasal lignocaine (lidocaine) 0.5 ml, oral aspirin 900 mg + metoclopramide 10 mg. 
  • Caveats
    • Age group studied: Unclear
    • Type/size: Review of RCTs and calculation of "number needed to treat"
    • Population characteristics: Patients with acute migraine
    • Outcome measures: Headache improved or relieved at 2 hr
    • Few studies and small numbers of patients
  • Citations
Non-Pharmacologic Therapy  
Guidelines for the diagnosis and treatment of migraine headache have been developed by the Canadian Headache Society:    (Most recommendations are supported by high quality evidence.)  Thermal biofeedback and interventions combining biofeedback and progressive muscle relaxation seem to be significantly more efficacious than other behavioral treatment modalities.  Other Headaches 
Pharmacologic Therapy  
No evidence is cited.  

Non-Pharmacologic Therapy 
Cognitive behavioral therapy (CBT) was investigated for the treatment of patients with medically unexplained physical symptoms. CBT reduced the frequency and intensity of physical symptoms, impairment of social interactions and sleep, and illness behavior at 12-month follow-up. The recovery rate was higher with cognitive behavioral therapy at 6 months but not at 12 months of follow-up. 

   
Monitoring 
No evidence is cited. 
  
Prognosis   
No evidence is cited.   
   
Prevention  
Migraine 
Guidelines for the diagnosis and treatment of migraine headache have been developed by the Canadian Headache Society:  
  • Few prophylactic medications have been subjected to adequate clinical trial. The aim is to use the least amount of the medication with the fewest side effects to gain control of the symptoms until the treatment can be stopped. Beta blockers (atenolol, metoprolol, nadolol and propranolol), calcium channel blockers (flunarizine and verapamil),  serotonin receptor antagonists, methysergide are amongst the drugs considered for this kind of management. (See Guideline for details)
  • Biofeedback is useful for the prevention of migraine (See Guideline for details)
  • Relaxation therapy is as effective as biofeedback. (See Guideline for details)
  • Cognitive-behavioral therapy is beneficial. (See Guideline for details)
  • Psychiatric referral of patients with migraine is not indicated except in the presence of a coexistent psychiatric disorder. (See Guideline for details)
  • Hypnosis may have a limited role in the management of migraine in a small subgroup of patients. (See Guideline for details)
  • The value and cost-effectiveness of physiotherapy, osteopathy and chiropractic in the management of migraine have not yet been determined. (See Guideline for details)
  • There is no firm evidence as to the benefits and cost-effectiveness of transcutaneous electrical stimulation and acupuncture. (See Guideline for details)
  • A trial of feverfew may be appropriate in prophylaxis, but there is a lack of evidence regarding the usefulness of other herbal therapies. (See Guideline for details)
  • There is no firm evidence as to the benefits and cost-effectiveness of naturopathy and homeopathy in the management of migraine. (See Guideline for details)
 (Most recommendations are supported by high quality evidence.)  Carbamazepine, clonazepam or valproate are effective in the prophylaxis of migraine headache. 
  • Caveats
    • Age group studied: Unclear
    • Type/size: Systematic review (3 RCTs = 151 patients)
    • Population characteristics: Patients with migraine

      • Outcome measures: Effectiveness, adverse effects 
    • Small numbers of patients
  • Citations
Given the low cost of riboflavin and the apparent lack of side effects, high dose riboflavin (400mg/d) prophylaxis seems to be worth trying for patients with two or more migraine headaches per month.     
Other Headaches 
The sparsity and poor quality of the data on the effects of manipulation or mobilization for people with headaches prevent a firm conclusion from being reached.     
Patient Education 
The following patient education materials are consistent with the available evidence. 
Rev. 7/8/99
   
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This Web site developed and maintained by Robert J. Flaherty, MD. 
Comments, additions and corrections are encouraged.