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Acute Migraine Treatment Guideline
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
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Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
IN RESPONSE:
Dr. Marino provides a very interesting account of her journey toward achieving relief from her migraines. Happily, she has found a preventive therapy that is effective for her. Dr. Marino cites several reports on the use of botulinum toxin therapy in migraine headache and asks why it was not included in the evidence review for the American College of Physicians guidelines. First, I must point out that the College's guideline is based on an exhaustive systematic review of the evidence, performed under the auspices of U.S. Headache Consortium (1, 2). These evidence reviews covered published studies up until the year 1998. In addition, only trials that were judged to be well-designed randomized, controlled trials could be included (3). In order for a recommendation to be made, many such trials directly relevant to the recommendation had to yield a consistent pattern of findings. Thus, the study by Binder and associates (4) that Dr. Marino cites would necessarily be excluded from the review because of its design (nonrandomized, uncontrolled, open-label).
Since completion of our review, a single randomized, double-blind, controlled trial of the use of botulinum toxin type A in migraine prevention has been published (5). Silberstein and associates studied 123 patients with a history of 2 to 8 moderate to severe migraine attacks per month. Participants were randomly assigned to receive 25 U or 75 U of botulinum toxin type A injection or injection of vehicle control. The authors concluded that pericranial injection of 25 U safely and substantially reduced migraine frequency (at 3 months) and severity (at 2 and 3 months). Of interest, those treated with 75 U showed no significant effects. Even if this trial had been available at the time of our review, however, we could not make a recommendation on the basis of a single small study. Further large-scale randomized, controlled studies are needed to confirm these results, identify the most efficacious doses, and demonstrate long-term efficacy and safety.
Vincenza Snow, MD
American College of Physicians; Philadelphia, PA 19106
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
