A small percentage of patients with intractable
migraine headaches do not respond to routine abortive treatments and may require additional analgesics. Benzodiazepines, opioids, and barbiturates are all options, but should not be used on a chronic basis since they are habit-forming and can contribute
The only therapy of rebound headaches is cessation of the offending drug.
Prophylactic therapy
A number of groups of medications are useful for the prophylactic treatment of migraine
Beta blockers
Several placebo-controlled studies have found that chronic therapy with propranolol reduces the frequency and severity of migraine in 60 to 80 percent of patients.
Other beta blockers may also be used. It may take several weeks for these drugs to become effective; the dose should be titrated and maintained for at least three months before deeming the medication a failure.
The use of beta blockers may be limited in patients with depression, impotence, or hypotension. They are contraindicated in those with asthma and heart block, and should be used with caution in patients with diabetes mellitus or congestive heart failure.
Calcium channel blockers
Calcium channel blockers are also effective for the prophylactic therapy of migraine. Advantages of these drugs over beta blockers include their relative safety and tolerance and relief of aura symptoms in addition to headache prophylaxis; they also do not exacerbate depression.
Verapamil is usually the first choice because of ease of use and favorable side effect profile. Tolerance may develop with calcium channel blockers. Tolerance may be overcome by increasing the dose of medication, or by switching to a different Calcium channel blocker.
Other drugs
Other agents that have shown efficacy for migraine prophylaxis include the tricyclic antidepressants, serotonin reuptake inhibitors (SSRIs), cyproheptadine, methysergide, and phenelzine, valproate, NSAIDs, and riboflavin.
