Percutaneous Interventional Strategies for Migraine Prevention: A Systematic Review and Practice Guideline.

Abstract

OBJECTIVE\nTo systematically evaluate the efficacy and effectiveness of percutaneous interventional treatments for prevention of migraine through a qualitative and (when possible) quantitative analysis.\n\n\nMETHODS\nAn expert panel was asked to develop recommendations for the multidisciplinary preventive treatment of migraine, including interventional strategies. The committee conducted a systematic review and (when evidence was sufficient) a meta-analytic review using GRADE criteria and the modified Cochrane risk of bias analysis available in the Covidence data management program. Clinical questions addressed adults with migraine who should be offered prevention. Examined outcomes included headache days, acute medication use, and functional impairment. Acute management of migraine was outside the scope of this guideline.\n\n\nRESULTS\nThe committee screened 1195 studies and assessed 352 by full text, yielding 16 randomized controlled trials that met inclusion criteria.\n\n\nRECOMMENDATIONS/CONCLUSIONS\nAs informed by evidence related to the preselected outcomes, adverse event profile, cost, and values and preferences of patients, onabotulinumtoxinA received a strong recommendation for chronic migraine prevention and a weak recommendation against use for episodic migraine prevention. Greater occipital nerve blocks received a weak recommendation for chronic migraine prevention. For greater occipital nerve block, steroid received a weak recommendation against use vs local anesthetic alone. Occipital nerve with supraorbital nerve blocks, sphenopalatine ganglion blocks, cervical spine percutaneous interventions, and implantable stimulation all received weak recommendations for chronic migraine prevention. The committee found insufficient evidence to assess trigger point injections in migraine prevention and highly discouraged use of intrathecal medication.