A Commonsense Approach to Acute Migraine Treatment

STOWE, VT —Patients with migraine require acute therapy that is individualized, according to Lawrence C. Newman, MD. Dr. Newman presented an overview of acute migraine therapy at the Headache Cooperative of New England’s 17th Annual Headache Symposium where he discussed the key points of treatment, including the importance of forming a strong therapeutic partnership with the patient, guidelines for physicians when interviewing patients, a review of available acute migraine agents, recommendations for matching treatment intensity to attack severity, considerations when­ initiating acute care, and the necessity for follow-up treatment.

A GROUP EFFORT

According to Dr. Newman, who is Director of the Headache Institute at St. Luke’s Roosevelt Hospital Center in New York City, establishing a strong therapeutic partnership that includes patient participation is a crucial first step in the successful treatment of acute migraine. “Patients need to take control of their own headache. They can’t just sit back and expect us as clinicians to do all the work,” he said. Physicians should educate patients on the nature of migraine and provide them with a list of common migraine triggers and strategies for identifying and avoiding them. Dr. Newman recommended that physicians encourage patients to record their migraine experience in a diary, including any triggers that precede their attacks. In addition, patients can be empowered through the implementation of nonpharmacologic treatment options such as exercise, regulation of sleep and diet, stress management, and biofeedback.

HISTORY MATTERS

Examining the patient’s successes and failures with past therapies, including both prescribed and over-the-counter medications, is key. Physicians should elicit the patient’s definition of successful treatment as well as the reasons they believe specific treatments may or may not have worked. It is also important to know the frequency of the patient’s migraine episodes so as to proactively avoid medication overuse. Physicians must be aggressive in determining the areas and the extent of disability that migraine may cause, Dr. Newman stressed. “Patients don’t tell us about their disability and clinicians all too often don’t ask.”

INDIVIDUALIZED CARE

Migraine varies from one patient to another and from one attack to another. Treatment must be individualized, Dr. Newman said, and multiple agents may be required. Treatment should be directed at the entire migraine, including pain and associated symptoms such as nausea and vomiting. When choosing a medication, physicians must take into account the patient’s level of disability, comorbid or coexisting conditions, the potential for interactions with other concomitant medications, and patient preference. The therapeutic agents used for migraine are divided into nonspecific agents (eg, simple analgesics, NSAIDs, opioids, neuroleptics, anti­emetics, and corticosteroids), and migraine-specific agents (eg, triptans and ergot alkaloids). Dr. Newman asserted that there is very little role, if any, for the use of butalbital and opioids in the treatment of migraine, due to the possibility of dependence and medication overuse syndrome, which leads to chronic daily headache.

“Most of us now realize it’s the [migraine-]specific agents that are necessary or foremost in the acute therapy for migraine headache.” These include two different ergot alkaloids (ergotamine and dihydroergotamine[DHE]) and seven triptans. These agents are available in various formulations with different pharmacokinetic properties and forms of administration, including oral, orally disintegrating, intranasal, subcutaneous, and intravenous.

Although few people still use oral ergot agents, according to Dr. Newman, DHE is available in a parenteral form, which is frequently used in emergency settings, and in a nasal spray. Intranasal DHE “is used for patients with nausea or vomiting, or for patients who may not respond to other agents,” he explained.

Any triptan is a reasonable choice, according to Dr. Newman. “Many people divide the triptans into two different categories: those that work quickly and those that take a little bit longer to work but have a longer half-life,” he observed. He expressed the opinion that all of the triptans are good, and the best triptan is “the triptan that works for the patient I am giving it to.” He further explained, “The triptans all have different strengths. The key that we’ve learned over the last several years is to start at a high dose to maximize efficacy, and if there are side effects, then back down.”

APPROACHES TO TREATMENT MAY VARY

“Treatment [selection] is not currently systematic,” Dr. Newman noted. Most current formal guidelines recommend a variant of strat­ified care in which patients with moderate to severe symptoms and disability, and those who have tried nonspecific agents without success, should be treated with migraine-specific therapies.” Dr. Newman ­described the process: “As the pain increases, and as the associated fea­tures become more pronounced, as they become more disabled, you stratify and go right toward one of the specific agents for migraine.” This approach was found superior to two forms of “stepped care” in the randomized Disability in Strategies of Care trial by Lipton et al, published in JAMA in 2000. Stepped-care approaches involve starting with a nonspecific agent, and moving to more specific agents in subsequent attacks or after a few hours during the same attack if the nonspecific agent fails to produce sufficient relief.

ASSESSING PATIENT, DISABILITY NEEDS

Assessment of disability is key to identifying the patient’s therapeutic needs. Physicians can easily assess disability using the Migraine Disability Assessment (MIDAS) questionnaire, which scores headache disability into ranges of low need, moderate need, and high need. Dr. Newman said that, using clinical judgment, physicians can select from treatment options matching the level of need:

• NSAIDs or analgesics for patients with low need, or triptans if the patient has infrequent but severe migraines;

• Combination analgesics or NSAIDs, antiemetics, or triptans for patients with moderate need;

• Triptans, ergots, or opioids for patients with high need.

In addition, patients with moderate or high need should be ­considered for prophylaxis, and ­high-need patients may require extended consultation. According to Dr. Newman, using stratified care to select an effective first-line agent can help prevent relapse and thereby reduce the number of subsequent consultations. In addition, during the first visit, physicians should provide recommendations for backup and rescue therapy. When patients understand that they have a comprehensive plan, they will feel more confident and will be less likely to need to contact a physician between visits for immediate care.

GAUGING THE APPROPRIATE TIME TO TREAT

Dr. Newman stressed that when treating migraine, timing is important. “The earlier your patients take these medications, the better they will do.” With a treatment delay of approximately 40 minutes or more after onset, central sensitization occurs and intravenous medication often becomes the only effective option. For the best treatment results, physicians must advise patients to take migraine medications while the pain is still mild. This decreases the likelihood that the headache will return hours later or the next day, and therefore less medication is needed over the long term.

Unfortunately, in headache specialty centers, follow-up visits are typically neglected, according to Dr. Newman. Such visits should be scheduled at the first consultation to review headache diaries and additional outcome measures and to determine whether treatment should be modified or switched. Dr. Newman was emphatic on this point, urging, “If you are giving the patient a diary, if you are giving the patient homework to do, please have the decency to look at it when they come back with it.” During follow-up visits, physicians should inquire as to the patient’s level of satisfaction, degree of disability, frequency of headaches, and use of acute treatments. Prophylaxis should­ be considered for patients who rely frequently on medication or who have persistent headaches despite appropriate use of acute treatments. Active, ongoing participation by both physicians and patients should help improve treatment outcomes and patient satisfaction with care.             

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