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Copyright © 2000 American Academy of Neurology

Special Article Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review)
Report of the Quality Standards Subcommittee of the American Academy of Neurology
Stephen D. Silberstein MD, FACP,
From the American Academy of Neurology, St. Paul, MN.

*Members of the US Headache Consortium are listed in Appendix 1on page 762.
Received April 6, 2000. Accepted in final form August 9, 2000.

Address correspondence and reprint requests to Wendy Edlund, American Academy of Neurology, 1080 Montreal Avenue, St. Paul, MN 55116; phone: 651-695-1940.

Approved by the Quality Standards Subcommittee April 1, 2000. Approved by the Practice Committee May 3, 2000. Approved by the AAN Board of Directors

June 9,2000.

The Evidence-Based Guidelines for Migraine Headache were supported by: Abbott Laboratories, Astra Zeneca, Bristol Myers Squibb, Glaxo Wellcome, Merck, Pfizer, Ortho-McNeil, and the AAN Education & Research Foundation, along with the seven participant member organizations.

Mission statement. The Quality Standards Subcommittee (QSS) of the American Academy of Neurology (AAN) is chargedwith developing practice parameters for physicians. This practice parameter summarizes the results from the four evidence-based reviews on the management of patients with migraine: specifically, acute, preventive, and nonpharmacologic treatments for migraine, and the role of neuroimaging in patients with headache. The full papers for these treatment guidelines are published elsewhere, [1] [ 2] [ 3][ 4] [ 5] [ 6] and only the specific treatment recommendations are summarized below.

Background and justification. Migraine is a very common disorder. An estimated 18% of women and 6% of men experience migraine, but many go undiagnosed and undertreated. [7] There have been a number of advances in the diagnosis and treatment of migraine as well as great strides in understanding itspathogenesis, making it one of the best understood of the neurologic disorders. Migraine is characterized by enhanced sensitivity of the nervous system. The attack is associated with activation of the trigeminal-vascular system. In June 1998, Duke University’s Center for Clinical Health Policy Research, in collaboration with the AAN, completed four Technical Reviews on migraine sponsored by the Agency forHealth Care Policy and Research. These reviews covered self-administered drug treatments for acute migraine [8] ; parenteral drug

treatments for acute migraine [9] ; drug treatments for the prevention of migraine [10] ; and behavioral and physical treatments for migraine. [11] The Education and Research Foundation of the AAN later funded additional reports on diagnostic testing for headachepatients, an update on sumatriptan and other 5-HT1 agonists, and a report on butalbital-containing compounds for migraine and tension-type headache, using the same methodology that was used in the original Technical Reviews. A multidisciplinary panel of professional organizations (The US Headache Consortium) produced four treatment guidelines, each related to a distinct set of management decisions:diagnostic testing (primarily neuroimaging studies), pharmacologic management of acute attacks, migraine-preventive drugs, and behavioral and physical treatments for migraine.

Clinical question statements. Specific clinical questions addressed in these practice parameters included the following: Acute and preventive treatment—What are the effects on acute headache pain of medications taken duringthe attack? What are the effects on the frequency and/or severity of migraine attacks of medications taken on a daily basis for prevention of migraine? How safe and tolerable are acute and preventive migraine medications? How do the efficacy and tolerability issues of medications for migraine compare to placebo, alternative medications, and nonpharmacologic techniques? Diagnostic testing—What is...
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