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Migraine is an episodic, often debilitatingcondition that affects women moreoften than men. Twenty-eight millionAmericans suffer from migraineheadaches-and nearly 75% of theseare women.1 Unlike other chronic painconditions, migraine has its peakprevalence during the years of greatestproductivity, when most women arejuggling family responsibilities andcareers.2 Many women are particularlysusceptible to migraine attacks justbefore and during menses.

Menstrual Migraine: How "Mini-Prophylaxis" Can Work for Your Patient

 to subscribe on your favorite streaming service.

The Primary Viewpoints podcast features informative conversations with health care experts, opinion leaders, and practicing physicians, about what impacts primary care medicine today.

In episode 14, headache specialist Dr Peter McAllister discusses the first FDA-approved migraine-specific oral preventive treatments in the gepant class and the role these medications may play in treatment of migraine in primary care settings.

 is medical director of the New England Institute for Neurology and Headache and chief medical officer of the Chief Medical Officer, New England Institute for Clinical Research, both located in Stamford, CT.

 to subscribe to the Primary Viewpoints podcast. Be sure to leave a rating and review for the show. Thanks for listening!

"Primary Viewpoints," a podcast from Patient Care Online, brings you an exclusive interview with headache specialist Peter McAllister, MD. 

Gepants for Migraine Prevention: A Perfect Fit for Primary Care

Beta-blocker therapy has for decades been the standard of care for patients who have suffered a myocardial infarction (MI). Although there have been no randomized controlled trials of beta-blocker use in patients with stable coronary artery disease (CAD) or with risk factors for coronary disease, extrapolation of the data on post-MI beta-blocker treatment has led to the widespread use of these drugs in this population. A new analysis of data from a large international registry, however, finds that use of beta-blockers in patients with and without a history of CAD does 

 reduce cardiovascular events. The study entitled, 

Beta-blocker use and clinical outcomes in stable outpatients with and without coronary artery disease

 was published online on October 2 in the 

Journal of the American Medical Association

• What assumptions about beta-blocker therapy are addressed in the study?

• Why did beta-blockers not show any benefit in the populations studied?

• What criteria should be used now to determine whether or not a beta-blocker is indicated in different patient types? 

• How should primary care clinicians proceed with patients currently taking beta-blockers?

Discussing the study and providing answers to these and other questions are Cardiology

 host Dr Payal Kohli of the University of California San Francisco and her guest, the first author of the study, Dr Sripal Bangalore. Dr Bangalore is Assistant Professor of Medicine at New York University School of Medicine where he also is the Director of Research for the Cardiac Catheterization Laboratory and Director of the Cardiovascular Outcomes Program.  


(1) The current practice of beta-blocker therapy in patients with risk factors for CAD or with established CAD without a previous acute coronary syndrome (ACS) is a result of extrapolation of data from original studies on the effect of these drugs in post-MI patients. When many of those studies were carried out, the potent medical therapies now routinely used and the practice of revascularization were not standard of care.

(2) This study reports that beta-blockers do not reduce the composite event rate of cardiovascular death/MI/stroke (at a mean follow-up time of 4.5 years) in patients with:
   a. Prior MI (several years after an ACS event)
   b. Known CAD/ischemia on stress testing
   c. Risk factors for CAD
The reason for this lack of efficacy is complex and may include improved use of background therapies, such as statins, aspirin, anti-platelet agents, and revascularization.

(3) Beta-blockers are still strongly indicated in patients with acute MI and patients with heart failure, and they should not be discontinued in these patients. In addition, alternative indications for beta-blocker therapy include migraine therapy, atrial fibrillation rate control, and stable angina. Although beta-blockers may provide symptom relief for these patients, they do not improve overall mortality in these groups.

(4) When determining whether or not to continue beta-blocker therapy for an individual patient, primary care physicians should consider the clinical trial evidence base, the indication for a beta-blocker, and the adverse-effect profile of these medications. It is reasonable to discontinue beta-blocker therapy in patients without another strong indication who fit into 1 of the 3 categories listed in (2), above.


1. Bangalore S, Steg G, Deedwania P, et al; for the REACH Registry Investigators. Beta-blocker use and clinical outcomes in stable outpatients with and without coronary artery disease. 


Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. 

A new analysis of data from a large international registry finds that use of beta-blockers in patients with and without a history of coronary artery disease does not reduce cardiovascular events.

Who Needs Beta-Blockers? Analysis Raises Questions

In many patients, episodic migraines increase in frequency and transform into a refractory pattern. What strategies can you employ to help avoid-or even reverse-this transformation?

 Here, Dr Susan Hutchinson, outlines 6 simple and effective steps you can take to help your patients combat chronic migraine. Dr Hutchinson is a headache specialist and family physician who practices in Orange County, California. She is the Founder of the Orange County Migraine Headache Center in Irvine.

Migraine-6 Steps to Counter Refractory Headaches

In many patients, episodic migraines increase in frequency and transform into a refractory pattern.

Podcast: Migraine-6 Steps to Counter Refractory Headaches

Migraine

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