Frequency of pediatric migraine with aura in a clinic-based sample

Calcitonin Gene-Related Peptide Inhibitors in the Treatment of Migraine in the Pediatric and Adolescent Populations: A Review

There are limited well-studied treatments for migraine in the pediatric population. Calcitonin gene-related peptide (CGRP) inhibitors are an established safe and effective treatment in adults, and use may be appropriate for pediatric patients in certain clinical situations. We describe migraine pathophysiology as it relates to CGRP, provide an overview of available medications, and discuss clinical usage in this population.

Headache in Children and Adolescents

OBJECTIVE

This article reviews the assessment of children and adolescents presenting with headache, provides an overview of primary headache disorders, and reviews evidence-based management of headache in this age group.

LATEST DEVELOPMENTS

In the last few years, new epidemiological data have shed light on less common pediatric headache disorders (eg, pediatric trigeminal autonomic cephalalgias) and psychosocial risk factors associated with primary headache disorders in children and adolescents. There has also recently been a substantial increase in interventions that target the calcitonin gene-related peptide pathway and that treat primary headache disorders using noninvasive neuromodulation. Although these interventions have primarily been studied in adults, there is emerging evidence of their use in the pediatric population.

ESSENTIAL POINTS

Primary headache disorders are very common in youth, and the most commonly encountered headache diagnosis in neurology practice is migraine, which affects approximately 10% of children and adolescents. Diagnosing and effectively treating primary headache disorders before adulthood may have a sustained impact on the patient by improving long-term headache and mental health outcomes, thereby significantly reducing the burden of disability over time. There are several available and emerging acute and preventive interventions for youth with primary headache disorders, and treatment decisions should be made in the context of available evidence using a shared decision-making approach.

A Narrative Review of Visual Hallucinations in Migraine and Epilepsy: Similarities and Differences in Children and Adolescents

Since the earliest descriptions of the simple visual hallucinations in migraine patients and in subjects suffering from occipital lobe epilepsy, several important issues have arisen in recognizing epileptic seizures of the occipital lobe, which often present with symptoms mimicking migraine. A detailed quantitative and qualitative clinical scrutiny of timing and characteristics of visual impairment can contribute to avoiding mistakes. Differential diagnosis, in children, might be challenging because of the partial clinical, therapeutic, and pathophysiological overlaps between the two diseases that often coexist. Ictal elementary visual hallucinations are defined by color, shape, size, location, movement, speed of appearance and duration, frequency, and associated symptoms and their progression. The evaluation of the distinctive clinical features of visual aura in migraine and visual hallucinations in occipital epilepsy could contribute to understanding the pathogenetic mechanisms of these two conditions. This paper aims to critically review the available scientific evidence on the main clinical criteria that address diagnosis, as well as similarities and differences in the pathophysiological mechanisms underlying the visual impairment in epilepsy and migraine.

Pediatric Chronic Orofacial Pain: A Narrative Review of Biopsychosocial Associations and Treatment Approaches

Pediatric chronic orofacial pain (OFP) is an umbrella term which refers to pain associated with the hard and soft tissues of the head, face, and neck lasting >3 months in patients younger than 18 years of age. Common chronic pediatric OFP diagnoses include temporomandibular disorder, headaches, and neuropathic pain. Chronic OFP can adversely affect youth's daily functioning and development in many areas of well-being, and may be associated with emotional stress, depression, functional avoidance, and poor sleep, among other negative outcomes. In this mini-review, we will discuss common psychological comorbidities and familial factors that often accompany chronic pediatric OFP conditions. We will also discuss traditional management approaches for pediatric orofacial pain including education, occlusal appliances, and psychological treatments such as relaxation, mindfulness-based interventions, and cognitive-behavioral treatments. Finally, we highlight avenues for future research, as a better understanding of chronic OFP comorbidities in childhood has the potential to prevent long-term pain-related disability in adulthood.

Headache and mental disorders in a nationally representative sample of American youth

The objective of this study is to examine the association between headache and mental disorders in a nationally representative sample of American youth. We used the National Comorbidity Survey-Adolescent Supplement to assess sex-specific prevalence of lifetime migraine and non-migraine headache using modified International Headache Society criteria and examine associations between headache subtypes and DSM-IV mental disorders. Adolescent report (n = 10,123) was used to identify headache subtypes and anxiety, mood, eating, and substance use disorders. ADHD and behavior disorder were based on parent report (n = 6483). Multivariate logistic regression analyses controlling for key demographic characteristics were used to examine associations between headache and mental disorders. Headache was endorsed by 26.9% (SE = 0.7) of the total sample and was more prevalent among females. Youth with headache were more than twice as likely (OR 2.74, 95% CI 1.94-3.83) to meet criteria for a DSM-IV disorder. Migraine, particularly with aura, was associated with depression and anxiety (adjusted OR 1.90-2.90) and with multiple classes of disorders. Adolescent headache, particularly migraine, is associated with anxiety, mood, and behavior disorders in a nationally representative sample of US youth. Headache is highly prevalent among youth with mental disorders, and youth with headache should be assessed for comorbid depression and anxiety that may influence treatment, severity, and course of both headache and mental disorders.

Outcomes of Migraine and Tension-Type Headache in Children and Adolescents

The aim of our study was to evaluate the long-term outcomes of pediatric migraine and TTH in a clinical setting. We conducted a cohort study. Pediatric patients who visited the pediatric neurology clinic due to diagnoses of migraine or TTH were contacted by phone 8–10 years after their initial diagnosis and interviewed about their outcomes. Of 147 children, we were able to reach 120 (81%) patients. Of these 120 patients, 59 were seen initially due to migraine and 61 due to TTH. For the migraine patients, headaches improved in 48 (81.4%) and worsened in four (6.8%). Regarding diagnosis at follow-up, 59% still had migraine, 17% had TTH, and 23% were headache-free. Aura and photophobia were significantly associated with persistence of a migraine diagnosis. For the TTH patients, headaches improved in 49 (81.7%) and worsened in nine (15.0%). Regarding diagnosis at follow-up, 36.7% still had TTH, 18.3% had migraine, and 45% were headache-free. Of the patients with TTH, 36.7% retained their initial diagnosis compared to 59.3% among the migraine patients. Most pediatric patients presenting with migraine or TTH will experience a favorable outcome over 10 years, with TTH patients having twice the chance of complete resolution.

Pediatric Episodic Migraine with Aura: A Unique Entity?

Migraine headache is a common cause of pain and disability in children and adolescents and is a major contributor to frequently missed school days and limitations in activities. Of children and adolescents with migraine headache, approximately one-third have migraine with aura (MA). MA is often considered to be similar to migraine without aura (MO), and thus, many studies do not stratify patients based on the presence of aura. Because of this, treatment recommendations are often analogous between MA and MO, with a few notable exceptions. The purpose of this review is to highlight the current evidence demonstrating the unique pathophysiology, clinical characteristics, differential diagnosis, co-morbidities, and treatment recommendations and responses for pediatric MA.

Migraine Symptoms Improvement During the COVID-19 Lockdown in a Cohort of Children and Adolescents

Background: Pediatric migraine is among the most common primary or comorbid neurologic disorders in children. Psychological stressors are widely acknowledged as potential triggers involved in recurring episodes of pediatric migraine. As the COVID-19 emergency may have affected the levels of stress perceived by children and adolescents with migraine, the present study was aimed to understand the effect of COVID-19 emergency on symptoms intensity and frequency in pediatric patients.

Methods: A cohort of 142 child and adolescent patients with a diagnosis of migraine was enrolled at the Child Neurology and Psychiatry Unit of the IRCCS Mondino Foundation in Pavia (Italy). Socio-demographic and clinical characteristics were obtained from medical records. An on-line survey was used to collect information on COVID-19 exposure, stress response to the lockdown period, anxious symptoms during COVID-19 emergency, as well as migraine symptoms intensity and frequency before and during the lockdown.

Results: The great majority were outpatients (n = 125, 88.0%), 52 (36.6%) had migraine with aura, whereas, 90 (63.4%) had migraine without aura. All the patients reporting worsening symptoms progression before COVID-19, had reduced intensity during the lockdown (χ² = 31.05, p < 0.0001). Symptoms frequency reduction was observed in 50% of patients presenting worsening symptoms before the lockdown, 45% of those who were stable, and 12% of those who were already improving. All patients who had resolved symptoms before COVID-19 were stable during the lockdown (χ² = 38.66, p < 0.0001). Anxious symptomatology was significantly associated with greater migraine symptoms frequency (χ² = 19.69, p < 0.001). Repeating the analysis separately for individuals with and without aura did not affect the findings and significant associations were confirmed for both the patients' subgroups.

Discussion: A significant reduction of migraine symptoms intensity and frequency was observed in pediatric patients during the COVID-19 lockdown phase in northern Italy. The improvement in both intensity and frequency of the migraine symptoms was especially significant in patients who were stable or worsening before the lockdown. The reduction of symptoms severity during a period of reduced environmental challenges and pressures further highlights the need of providing effective training in stress regulation and coping for these patients.

Imaging Neurovascular Uncoupling in Acute Migraine with Aura with Susceptibility Weighted Imaging

PURPOSE

Migraine with aura (MwA) in the emergency setting is common and sometimes difficult to distinguish from mimicking conditions. Susceptibility weighted imaging (SWI), a magnet resonance (MR) technique is sensitive to deoxygenated hemoglobin in cerebral veins and depicts these according to their level of oxygenation. Our study aimed at evaluating the frequency of regions of prominent focal veins (PFV) on SWI in the acute phase.

METHODS

Between 2011 and 2018 we evaluated symptoms and MR imaging of adult patients with acute MwA attacks (< 5 days after onset of symptoms). Abnormal imaging was visually scored in 12 ROIs on both hemispheres distributed on 3 slices. The score ranged from 0 to 3.

RESULTS

In all, 638 patients (436 female) mean age 37.39 years (18-89 ± 14.13) were included. Susceptibility weighted imaging was abnormal in 18.8% of patients. The inferior and posterior medial temporal lobe and the occipital lobe were most often affected. Susceptibility weighted imaging was more likely abnormal when MR was performed within 24 hours with an average around 5 hours after symptom onset. The side of aura symptoms and hemispheric imaging alteration in patients with abnormal SWI was highly significant (p < 0.001).

CONCLUSION

In the acute episode of MwA, SWI imaging can show a combination of increased deoxygenation. The results may indicate linking PFV to MwA.

Findings in susceptibility weighted imaging in pediatric patients with migraine with aura

BACKGROUND

Migraine with aura (MwA) in pediatric patients is clinically frequent. Clinically complex symptoms need to be differentiated to exclude mimicking conditions.

PURPOSE

We hypothesize that MwA in children induces abnormalities readily visible in perfusion time to peak (TTP) maps as well as non-enhanced susceptibility weighted magnetic resonance imaging (SWI).

MATERIALS AND METHODS

Between 2010 and 2018, we retrospectively evaluated symptoms and imaging of consecutive pediatric patients <18 years with MwA. We visually scored abnormalities on SWI and TTP maps in 12 regions of interest on both hemispheres on three axial slices, as normal, slightly, distinctly or severely abnormal.

RESULTS

99 patients (69.7% female), mean age 14.07 y (±2.8) were included. Focally increased deoxygenation (FID) in SWI was present in 61.6%. FID on SWI was dominant for the left hemisphere (60.7% vs. 31.1%, (p < .001)), and in 8.2% symmetric. Side of aura symptoms and contralateral hemispheric imaging alterations in patients with FID correlated significantly (p = .002.). 61 of 99 patients had perfusion MR and 59% of these patients showed focal increase of TTP. Age correlated significantly with FID in SWI (r = -.248, p = .013) and increase of TTP in perfusion (r = -.252, p = .05). Focal abnormalities correlated significantly between SWI and TTP maps. Brain regions most often abnormal were the temporal superior, occipital and fronto-parietal regions.

CONCLUSIONS

This study provides confidence in recognizing FID, and linking FID in SWI to acute MwA in pediatric patients. FID phenomenon had a left hemispheric significant dominance, and can be found bilaterally.

Associations between migraine occurrence and the effect of aura, age at onset, family history, and sex: A cross-sectional study

Introduction

The relationships between family history, sex, age at onset, and migraine occurrence have been documented. However, the associations between these factors across different sexes and subgroups of patients have yet to be elucidated. This study evaluated the association between family history and migraine in male and female patients experiencing episodic and chronic migraine with and without aura.

Methods

This cross-sectional, case–control study included 299 headache-free controls and 885 patients receiving outpatient treatment for migraine. Participants were classified into episodic (1–14 days/month) and chronic (≥15 days/month) migraine groups.

Results

Positive family history was significantly more frequently observed in the episodic group than in the chronic group (49.5% vs. 26%; P < 0.001) in male patients, particularly in male patients without aura (50.3% vs. 21.9%; P = 0.003); it was less frequently observed (58.7% vs. 73.7%; P = 0.048) in female patients with aura. Family history was correlated with an earlier age at onset (20.7 years vs. 22.8 years; P = 0.002), particularly in patients without aura (21 years vs. 23.7 years; P = 0.002), who were women (20.9 years vs. 23.9 years; P = 0.002).

Conclusions

Different patterns of association between family history and migraine can be observed between men and women. A positive family history of migraine is correlated with an earlier age at onset, particularly among female patients without aura.

Management of Childhood Headache in the Emergency Department. Review of the Literature

Headache is the third cause of visits to pediatric emergency departments (ED). According to a systematic review, headaches in children evaluated in the ED are primarily due to benign conditions that tend to be self-limiting or resolve with appropriate pharmacological treatment. The more frequent causes of non-traumatic headache in the ED include primitive headaches (21.8–66.3%) and benign secondary headaches (35.4–63.2%), whereas potentially life-threatening (LT) secondary headaches are less frequent (2–15.3%). Worrying conditions include brain tumors, central nervous system infections, dysfunction of ventriculo-peritoneal shunts, hydrocephalus, idiopathic intracranial hypertension, and intracranial hemorrhage. In the emergency setting, the main goal is to intercept potentially LT conditions that require immediate medical attention. The initial assessment begins with an in-depth, appropriate history followed by a complete, oriented physical and neurological examination. The literature describes the following red flags requiring further investigation (for example neuroimaging) for recognition of LT conditions: abnormal neurological examination; atypical presentation of headaches: subjective vertigo, intractable vomiting or headaches that wake the child from sleep; recent and progressive severe headache (<6 months); age of the child <6 years; no family history for migraine or primary headache; occipital headache; change of headache; new headache in an immunocompromised child; first or worst headache; symptoms and signs of systemic disease; headaches associated with changes in mental status or focal neurological disorders. In evaluating a child or adolescent who is being treated for headache, physicians should consider using appropriate diagnostic tests. Diagnostic tests are varied, and include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography or magnetic resonance neuroimaging. The management of headache in the ED depends on the patient's general conditions and the presumable cause of the headache. There are few randomized, controlled trials on pharmacological treatment of headache in the pediatric population. Only ibuprofen and sumatriptan are significantly more effective than placebo in determining headache relief.

Premonitory Symptoms in Episodic and Chronic Migraine From a Pediatric Headache Clinic

OBJECTIVE

We evaluated the frequency of six commonly reported adult migraine premonitory symptoms in children and adolescents with episodic and chronic migraine and elicited psychological or behavioral comorbidities that may be associated with these symptoms.

BACKGROUND

Premonitory symptoms are commonly reported in the adult migraine population; however, little information is available for the pediatric population.

METHODS

Data were collected on new patients being evaluated in our multidisciplinary pediatric headache clinic over a six-month time interval. The data collected from patients diagnosed with migraine were then reviewed for the following premonitory symptoms: yawning, neck stiffness, fatigue, increased urination, mood changes, and food cravings. History was obtained regarding the frequency of headaches and other associated behavioral or psychological problems.

RESULTS

A total of 176 patients were enrolled over a six-month interval, ranging in age from four to 18 years (mean age 12 years); 64% were female, and 42% (74 of 176) of the subjects had at least one premonitory symptom. Patients with migraine with aura were noted to have a significantly higher association with premonitory symptoms (59%, 30 of 51) (P < 0.05). Anxiety disorder was also significantly associated with premonitory symptoms (55%, 11 of 20) (P < 0.05). Fatigue and mood changes were the most commonly reported premonitory symptoms.

CONCLUSIONS

Premonitory symptoms occurred frequently in our population of pediatric patients with migraine. Fatigue and mood changes were the most frequent symptoms. There were no significant differences in premonitory symptoms by gender or age group (less than 12 years versus greater than 12 years). Anxiety and migraine with aura were correlated with an increased likelihood of premonitory symptoms.

Increased pain sensitivity but normal pain modulation in adolescents with migraine

Inhibitory pain modulation has been reported to be deficient in adults across different types of chronic pain, including migraine. To determine whether a similar phenomenon occurs in youth, we performed a quantitative sensory testing investigation in adolescents with migraine (N = 19). These patients were compared to healthy adolescents with (Fam-His; N = 20) or without (Healthy; N = 29) a family history of migraine (eg, first-degree relative with migraine). Subjects were first familiarized with the stimuli and visual analogue rating scales using graded noxious stimuli (0°C, 43-49°C range). These data were used to explore potential pain sensitivity differences between the groups. Pain inhibition was assessed by conditioned pain modulation (CPM), which used both suprathreshold heat pain (heat CPM) and pressure pain thresholds (pressure CPM) as the test stimuli before and during cold-water immersion (8°C). In response to the graded heat stimuli, Fam-His participants reported higher pain intensity ratings compared with patients with migraine, who in turn reported higher pain intensity ratings than the healthy controls (F = 3.6, [df = 2, 459], P = 0.027). For heat and pressure CPM, there was no significant group difference in the magnitude of CPM responses. Thus, adolescents with migraine and healthy adolescents have similar inhibitory pain modulation capability, despite having marked differences in pain sensitivity. Although Fam-His participants are asymptomatic, they demonstrate alterations in pain processing, which may serve as markers for prediction of migraine development.

Perivascular neurotransmitters: Regulation of cerebral blood flow and role in primary headaches

In order to understand the nature of the relationship between cerebral blood flow (CBF) and primary headaches, we have conducted a literature review with particular emphasis on the role of perivascular neurotransmitters. Primary headaches are in general considered complex polygenic disorders (genetic and environmental influence) with pathophysiological neurovascular alterations. Identified candidate headache genes are associated with neuro- and gliogenesis, vascular development and diseases, and regulation of vascular tone. These findings support a role for the vasculature in primary headache disorders. Moreover, neuronal hyperexcitability and other abnormalities have been observed in primary headaches and related to changes in hemodynamic factors. In particular, this relates to migraine aura and spreading depression. During headache attacks, ganglia such as trigeminal and sphenopalatine (located outside the blood-brain barrier) are variably activated and sensitized which gives rise to vasoactive neurotransmitter release. Sympathetic, parasympathetic and sensory nerves to the cerebral vasculature are activated. During migraine attacks, altered CBF has been observed in brain regions such as the somatosensory cortex, brainstem and thalamus. In regulation of CBF, the individual roles of neurotransmitters are partly known, but much needs to be unraveled with respect to headache disorders.

Brain Diffusion Abnormalities in Children with Tension-Type and Migraine-Type Headaches

BACKGROUND AND PURPOSE

Tension-type and migraine-type headaches are the most common chronic paroxysmal disorders of childhood. The goal of this study was to compare regional cerebral volumes and diffusion in tension-type and migraine-type headaches against published controls.

MATERIALS AND METHODS

Patients evaluated for tension-type or migraine-type headache without aura from May 2014 to July 2016 in a single center were retrospectively reviewed. Thirty-two patients with tension-type headache and 23 with migraine-type headache at an average of 4 months after diagnosis were enrolled. All patients underwent DWI at 3T before the start of pharmacotherapy. Using atlas-based DWI analysis, we determined regional volumetric and diffusion properties in the cerebral cortex, thalamus, caudate, putamen, globus pallidus, hippocampus, amygdala, nucleus accumbens, brain stem, and cerebral white matter. Multivariate analysis of covariance was used to test for differences between controls and patients with tension-type and migraine-type headaches.

RESULTS

There were no significant differences in regional brain volumes between the groups. Patients with tension-type and migraine-type headaches showed significantly increased ADC in the hippocampus and brain stem compared with controls. Additionally, only patients with migraine-type headache showed significantly increased ADC in the thalamus and a trend toward increased ADC in the amygdala compared with controls.

CONCLUSIONS

This study identifies early cerebral diffusion changes in patients with tension-type and migraine-type headaches compared with controls. The hypothesized mechanisms of nociception in migraine-type and tension-type headaches may explain the findings as a precursor to structural changes seen in adult patients with chronic headache.

Pediatric migraine with aura in an Italian case series

The aim of the present study was to describe the characteristics of migraine with aura (MwA) in a case series of patients with headache onset before 12 years of age. We considered all consecutive patients referred to the Parma Headache Centre between 1975 and 2015 affected by MwA, diagnosed by our team of trained neurologists; the cases were subsequently reviewed applying the ICHD3-beta criteria. We then identified those cases with headache age-of-onset <12 years (i.e., "pediatric" cases), which were compared to all remaining cases. We identified 283 cases with pediatric onset (87 males and 196 females). The male-to-female ratio was 1:2.3 in both "pediatric" and "non-pediatric" cases. The time lag between MwA onset and our first evaluation was significantly higher among the pediatric cases (18.7 ± 13.3 vs 10.4 ± 10.4 years). In both groups of patients, visual aura was the most common type of aura, followed by sensory and speech disturbances; however, these two latter aura symptoms were significantly more common among pediatric cases. In this group of patients, aura without headache was significantly less frequent (1.8 vs 5.3%); furthermore, headache had migraine characteristics in a higher proportion of cases (90.1 vs 82.6%). A family history of MwA was significantly more frequent among cases with pediatric onset (31.1 vs 16.9%). Males but not females with pediatric MwA had more frequently a comorbid migraine without aura (27.6 vs 16.8%). Among cases with pediatric onset, we did not find any significant differences between males and females. In conclusion, in our very large case series of MwA, patients with headache onset before 12 years of age seem to have a specific clinical phenotype, without significant gender differences.

Experts' opinion about the primary headache diagnostic criteria of the ICHD-3rd edition beta in children and adolescents

BACKGROUND

The 2013 International Classification of Headache Disorders-3 (ICHD-3) was published in a beta version to allow the clinicians to confirm the validity of the criteria or to suggest improvements based on field studies. The aim of this work was to review the Primary Headache Disorders Section of ICHD-3 beta data on children and adolescents (age 0-18 years), and to suggest changes, additions, and amendments.

METHODS

Several experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the literature available on pediatric headache, they made observations and proposed suggestions for the primary headache disorders section of ICHD-3 beta data on children and adolescents.

RESULTS

Some headache disorders in children have specific features which are different from those seen in adults and which should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psycho-social basis in children and adolescents making primary headache disorders in children distinct from those in adults.

CONCLUSIONS

Several recommendations are presented in order to make ICHD-3 more appropriate for use with children.

Are there any changes in posterior ocular structure parameters in pediatric migraine patients?

PURPOSE

To evaluate the thickness of the peripapillary retinal nerve fiber layer (RNFL), total macula, macular ganglion cell layer (GCL), inner plexiform layer (IPL), and choroid in pediatric migraine patients and compare the values with healthy subjects.

METHODS

This observational and cross-sectional study included 40 patients in the migraine group and 40 healthy control subjects. The thickness of the peripapillary RNFL, total macula, GCL, and IPL was analyzed with spectral-domain optic coherence tomography, while choroidal thickness was analyzed with the enhanced depth imaging protocol. All measurements of the migraine patients were taken in the attack-free period. Right eye selected per subject was included in the study.

RESULTS

There was no significant difference between the 2 groups in age or sex (p>0.05). The peripapillary RNFL thickness was not significantly different between the 2 groups in any quadrant. The total macula, GCL, and IPL thickness were also not significantly different in the 9 separate macular areas defined on the basis of the Early Treatment Diabetic Retinopathy Study (p>0.05). The choroidal thickness at 5 different measurement points was not statistically significantly different between migraine patients during the attack-free period and the healthy subjects (p>0.05).

CONCLUSIONS

Childhood migraine does not cause changes in posterior ocular structure parameters.

Diagnosis and Treatment of Childhood Migraine

OPINION STATEMENT

While the diagnosis of migraine in children is generally straightforward, treatment can seem complex with a number of medication choices, many of which are used "off label." Patients with intermittent migraines can often be managed with ibuprofen or naproxen taken as needed. Unfortunately, by the time that children present to our practice, they have often tried these medications without improvement. Triptans are frequently prescribed to these patients with good success. It is important to make the patient aware of the possible associated serotonergic reactions. If the patient is having more than one headache per week or the headaches are prolonged, prophylactic treatment is indicated. In our practice, the overwhelming majority of these patients will be treated with amitriptyline or topiramate. We generally allow side effect tolerability to guide our choice of medication. Cyproheptadine is often used in younger patients as it comes in a liquid form. There is evidence supporting the use of propranolol, though the potential worsening of underlying asthma symptoms may limit its use, and sodium valproate, which must be used with caution in female patients of childbearing age due to significant teratogenicity risks. Other prophylactic treatments with less robust evidence include the antiepileptic drugs gabapentin, zonisamide, and levetiracetam; calcium channel blockers such as verapamil and amlodipine; and the angiotensin receptor blocking agent candasartin (not available in the USA). Almost all patients in our practice are advised to take magnesium supplementation. Magnesium is a supplement with relatively few adverse effects and good evidence for improvement of migraine symptoms. We evaluate lifestyle issues and comorbidities in all our patients. Ignoring these will make successful treatment near impossible. Good sleep, adequate hydration, appropriate diet, and exercise are vitally important. Finally, most of our patients benefit from a psychology evaluation with cognitive behavioral therapy. Stress management and biofeedback are tremendously helpful in improving quality of life in migraineurs.