An ounce of prevention


Migraine Prophylaxis

A few weeks ago we talked about types of headaches and how to diagnose.  Another headache issue that comes up often in clinic is prevention.

You should think about prophylactic medicines in your patients who have more than 3-4 severe headaches a month, headaches lasting more than 12 hours, or really in anyone who feels like they have enough headaches that it is worth it to them to take a daily (sometimes more than daily) medicine to prevent headaches.  It is also helpful in those who you are concerned about rebound headaches, to help them use less of their abortive medicine.

Typical results are 50-75% of patients get 50% reduction in headaches- either intensity or frequency.  Can take a month to see results, and up to 3 months to get peak results. You have to titrate medicines to good doses, and leave the patients there for a while to give a good trial of therapy. I’ve listed some  medicines and typical doses below.

Beta Blockers

Fairly good data for the more selective: metoprolol, propranolol, and timolol.
Less data for atenolol.
Often limited by blood pressure and heart rate, but titrate to reasonable doses (heart rate 60-70s)

Calcium Channel Blockers

Verapamil (120-240mg divided daily) and Nifedipine have some, albeit weak, data.

ACE Inhibitors

One trial for Lisinopril and one for Candesartan showed benefit. Leads me to think that perhaps any blood pressure lowering may be helpful for migraines.

Antidepressants

Tricyclics: amitriptyline most commonly, and most studied, but other should work as well. 20-50mg at bedtime
Venlafaxine 75-150mg daily.  More data with this than with traditional SSRIs.

Anticonvulsants

Valproic Acid 500-1500mg daily. Side effects of weight gain, somnolence, hair loss Can’t use in women of childbearing age
Topiramate 25-100mg daily. Side effects weight loss, confusion/concentration issues/memory loss

picture is totally unrelated, but I just thought it was funny. Cigarettes are not recommended for migraine prophylaxis

UPDATE

Just came across this article JGIM (subscription or UAB access needed).  The authors systematically reviewed drug trials for migraine prophylaxis.  Turns out, everything studied (those things listed above) work fairly equally well.  All reduce headache frequency by about 50%. Antiepileptics and antidepressants had more side effects, and were more likely to be stopped.
  • take home point: think about beta blockers and ACE-I/ARBs for migraine prophylaxis, as they have the best risk/benefit ratio.
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Skin Deep

It’s time for this blog to live up to its name and do a dermatology post.   Today… topical steroids.  This was always kind of a black box for me, I never knew which steroid to pick, and sort of did so randomly.  But there is some method to the madness if you understand relative potency.  Target the condition and the location with the right potency and you will be in good shape.  The thicker the skin or the “thicker” the dermatitis, the higher potency medicine you will need to penetrate it.  Also, higher potency creams come with higher risk for side effects- thinning skin, telangiectasias, and even systemic absorption.  So use them sparingly and for a short a time as possible.
A word about vehicles.  The more “goopy” an agent is, the more potent.

There are some other interesting vehicles available.  In general, a gel will give the potency of the ointment without the grease factor.  Foams are handy for hairy areas- Clobetasol (Olux) foam is
useful for thick seborrheic dermatitis or psoriasis in the hairline. 

You can also increase the potency by putting something under occlusion, either by covering it with an emollient like Vaseline or by simply covering it with a bandage, or the ever helpful white cotton sock.

On with the list. I would suggest learning one or two choices for a super high, high, and low potency steroid and just stick to those.  I’ve added some brand names below because those are easier to remember. Simplify, simplify, simplify…

Super High Potency: Class 1 
Think thick: thick skin or thick plaques of dermatitis
Location: palms and soles
Disease: severe dermatitis (contact or allergic/eczema), psoriasis
Duration: less than 3 weeks
Agents: Betamethasone diproprionate(Diprolene), Clobetasol proprionate (Temovate or Olux foam)
High Potency: Classes 2-3 
Location: arms/legs, back, trunk
Duration: 6-8 weeks
Agents: 0.5% triamcinolone ointment (Kenalog), Fluocinonide (Lidex)
Medium Potency: Classes 4-5
Location: face, intertriginous areas, large areas (risk of systemic absorbtion)
Agents: 0.1% triamcinolone ointment (Aristocort), 0.1% Hydrocortisone butyrate (Locoid)
Low Potency: Classes 6-7. 
Think thin: thin skin, not much disease. This is where the OTC steroid creams are.  
Location: eyelid, genitalia 
Agents: 0.5% Hydrocortisone base (Cortaid)