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Topic: Preventive meds: when to stop? (Read 797 times) |
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Bob_Johnson
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Preventive meds: when to stop?
« on: Dec 14th, 2004, 9:45am » |
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Posting his report only to indicate that we are not alone in wrestling with this hard question. [Edited to fit.]
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When Can Successful Migraine Prophylaxis Be Discontinued?
Randolph W. Evans, MD; Elizabeth Loder, MD, FACP; David M. Biondi, DO
Headache 44(10):1040-1042, 2004. © 2004 Blackwell Publishing
The clinical questions highlighted by this case—when, whether, and how to discontinue successful migraine prophylaxis—have received far less attention and study than the question of when to begin migraine prophylaxis. We cannot look for answers to clinical trials of migraine preventives, since they are designed to demonstrate treatment efficacy rather than determine its optimal length or show an effect on the natural history of the disorder.
Uncertainty about the optimal duration of prophylactic therapy is not unique to migraine. Subgroups of migraineurs have been identified in whom negative prognostic factors suggest an increased likelihood of headache progression..... Long-term prophylaxis for those groups may be advantageous.
A suggestion that this is true comes from a follow-up study of 64 migraine patients who discontinued successful prophylaxis. In that study, 25% of patients experienced persistent reduction of migraine frequency, while 75% experienced relapse. Second and third attempts at prophylaxis using the same drug were not as successful as the initial attempt.[5] Based on these results, prophylaxis for longer than 6 months was recommended for patients with negative prognostic factors. The authors also suggested that a different class of preventive agent should be used when prophylaxis was reinstituted; this is in contrast to the usual clinical practice of resuming the previously effective prophylactic agent.
However, it is reasonable to hypothesize that prophylactic treatment for migraine, especially if used early, may have long-term benefit in reducing headache activity, preventing transformation to chronic headache, limiting the appearance of structural central nervous system changes, or minimizing disability. Our practice is to recommend at least 6 months of good migraine control prior to considering a slow taper and potential discontinuance of migraine prophylaxis for patients who experience less frequent migraine attacks, have fewer years of migraine, and present with fewer comorbid conditions such as depression, anxiety, and fibromyalgia, whereas at least 12 months of good control is advised for patients who have a longer migraine history, chronic migraine, and multiple comorbid conditions.
Meanwhile, in the absence of clear evidence about how long prophylaxis should be continued, patient preferences and opinions should be elicited and respected. The patient in this case is inquiring about discontinuation. This suggests that she is one of the many patients who desire to avoid daily use of medication, or dislikes some of the unintended effects of the drug she is taking. Other patients, though, especially those whose headaches before treatment were especially severe, disabling, or poorly controlled, express a strong preference for long-term continuation of prophylaxis. Some wish to continue treatment indefinitely because it controls not only migraine but also a comorbid condition (hypertension, depression or obesity, for example).
Prophylaxis discontinuation does not have to be "all or nothing." An alternative for this patient is weekly or monthly dosage reduction—to 75, 50, and then 25 mg daily—rather than abrupt elimination. This allows systematic evaluation of the possibility that maintenance of headache control might be achieved at doses lower than those needed to induce initial remission, even if medication elimination ultimately is not successful.
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Bob Johnson
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justin
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Re: Preventive meds: when to stop?
« Reply #1 on: Jan 2nd, 2005, 1:29am » |
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this is a really important question. i HATE taking these drugs, but i can not do the shroom thing. i just can't at this point in my life. i really hate drugs and get super paranoid and freak out. anyway...when do you just clean your system and stop everything and try again, or just do something else. i hate to think i'm on these drugs for the rest of my life or till at least 60. i'm only 25. such is life
j
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justin
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Re: Preventive meds: when to stop?
« Reply #2 on: Jan 2nd, 2005, 7:27pm » |
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wow you can tell it was really late when i posted that post above. becuase i'm 26 not 25! ha
anyway. yeah i just mean that i would like to try to lower my medication but everytime i do the ch's get worse.
there are so many new medications for clusters and migraines that long term studies aren't really available. the fda doesn't make them mandatory for that long i guess. but that can be good or bad. good for us when we need something to come out, but bad for say vioxx users.
but hopefully as time goes by dr's will have a better idea of long term use, discontinuation, or reinstating of depakote, and neurontin, and verapamil, etc.
good questions
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don
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Re: Preventive meds: when to stop?
« Reply #3 on: Jan 2nd, 2005, 7:54pm » |
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Heres the short version:
No hits, no shadows for 2 straight weeks, begin to taper off.
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Not4Hire
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Re: Preventive meds: when to stop?
« Reply #4 on: Jan 3rd, 2005, 8:18pm » |
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dear justin:
you said:
Quote:| there are so many new medications for clusters and migraines that long term studies aren't really available. |
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I really don't know about these "new" medications for CH (&M) you refer to... (what are they and where can we buy them?)..
but I suspect your point was *the long term studies" .....
me thinks...the only *long term* drugs that humanity have been on (and have been REAL extensively studied/drunken/smoked) are :
...alcohol
...opiates
...cannabis
...and maybe licking frogs..... 
..ALL ...I say...ALL..... (OK...MOST of) the rest of the drugs that we are are being encouraged to take have been invented in the last century....
and not by people with our best interest in mind....
but by people with $$$/dollars/ducats/cash/profit in mind....
*results* and *healing* and *treating ***causes*** for disease (not SYMPTOMS) seem to take a back seat...
...sorry for hijacking your thread with my RANT.....
notfer....
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Kris_in_SJ
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Re: Preventive meds: when to stop?
« Reply #5 on: Jan 3rd, 2005, 8:37pm » |
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I only know that I'd been on one dose or another of Verapamil for over 6 years. First prescribed for CH, then continued for hypertension, then increased for hypertension. When my last cycle hit, I was already on 240mg/day - rapidly increased to 480mg. I decided to wean off totally after cycle - afterall, there are other hypertension drugs on the market.
Took me 5 months - got stuck for quite awhile at 240/day - but now I'm off. I've started on a different drug for hypertension (not a calcium-channel blocker) that seems to work. My goal was to be clean enough for next cycle that I could try alternative treatment. Barring that, I wanted to be sure the Verap would still work for me.
In other words, it takes some time, and each time you reduce dosage you have "twinges" that remind you the beast still lingers. The twinges decreased for me though, and each time they did, I reduced dosage.
Wow - really long letter for a fairly simple question. Sorry!
Kris
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don
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Re: Preventive meds: when to stop?
« Reply #6 on: Jan 3rd, 2005, 10:47pm » |
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I am a living long term study
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Sean_C
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Re: Preventive meds: when to stop?
« Reply #7 on: Jan 3rd, 2005, 10:55pm » |
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Cool thread Bob
Sean...................................
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