LOS ANGELES—Changing medications does not necessarily benefit patients with migraine who take a triptan, and it sometimes results in increased headache-related disability, researchers reported at the 54th Annual Scientific Meeting of the American Headache Society.
For patients who switched from one triptan to another, Migraine Disability Assessment (MIDAS) score, which measures days of headache-related disability over three months, did not change from one year to the next. MIDAS score increased by 4.9 points for patients who switched from a triptan to a nonsteroidal anti-inflammatory drug (NSAID), and by 5.7 points for patients who switched from a triptan to an opioid or barbiturate. MIDAS scores decreased by 0.4 points for patients who continued to take the same triptan, said Dawn C. Buse, PhD, Associate Professor of Clinical Neurology at Albert Einstein College of Medicine and Montefiore Medical Center in Bronx, New York.
For patients with chronic migraine or high-frequency episodic migraine who take a triptan, adding a second triptan is associated with increased headache-related disability, according to Richard B. Lipton, MD, Edwin S. Lowe Chair in Neurology at Albert Einstein College of Medicine and Director of the Montefiore Headache Center. Adding a second triptan does not affect disability for patients with low-frequency or moderate-frequency episodic migraine, however.
Adding an NSAID to current triptan therapy is beneficial for patients with moderate-frequency episodic migraine but does not affect patients with low-frequency episodic migraine. For patients with high-frequency episodic migraine or chronic migraine, adding an NSAID is associated with increased disability.
American Migraine Prevalence and Prevention Study
Drs. Buse and Lipton and colleagues analyzed data from the American Migraine Prevalence and Prevention study to determine whether switching or adding treatments improved outcomes for patients with migraine. In that study, 24,000 individuals with severe headache responded to annual surveys between 2005 and 2009. Eligible subjects for the researchers’ analyses met International Classification of Headache Disorders-2 criteria for migraine, had pharmacologic data for at least two consecutive years, and were taking a triptan during their first year of data.
The investigators examined acute medication use during the patients’ first two years of data. To determine the effects of switching medications, the researchers classified patients as having maintained their original triptan use, switched to a different triptan, switched to an NSAID, or switched to opioids or barbiturates.
To assess the outcomes of adding treatments to triptan therapy, the investigators categorized patients into a group who added no treatment, a group who added a second triptan, a group who added an NSAID, and a group who added a combination analgesic containing opioids or barbiturates.
Patients with episodic migraine were categorized as low-frequency (ie, four or fewer headache days per month), moderate-frequency (ie, five to nine headache days per month), and high-frequency (ie, 10 to 14 headache days per month). To get a larger sample size, the researchers combined patients with chronic migraine and patients with high-frequency episodic migraine into one group.
Switching to NSAIDs May Worsen Outcomes for Certain Patients
Of the 799 individuals included in the analysis, 667 used the same triptan for two years, 81 switched to another triptan, 20 switched to an NSAID, and 31 switched to analgesics containing opioids or barbiturates. Switching from a triptan to an NSAID was associated with a significant increase in headache- related disability among patients with high-frequency episodic or chronic migraine, compared with patients with low- and moderate-frequency episodic migraine.
Among patients with high-frequency episodic migraine, MIDAS sum scores decreased by 8.7 points for patients who kept taking the same triptan and increased by 26.3 points for patients who switched to an NSAID. “Not only did the treatment matter, but the average number of headache days at baseline was important,” said Dr. Buse.
This difference was not seen among patients with low-frequency episodic migraine. In that group, remaining on the same triptan and switching to an NSAID were associated with average increased MIDAS sum scores of 12.3 and 12.5, respectively. This result indicated that treatment differences were not associated with dramatic differences in MIDAS sum scores for this group in the same way that they were for the high-frequency episodic migraine group.
The increase in MIDAS scores for patients with high-frequency episodic migraine who added an NSAID to triptan therapy “is analogous to the finding in the Bigal paper showing that NSAIDs are associated with an increased risk of the transition to chronic migraine in people who have high-frequency episodic migraine,” noted Dr. Lipton. MIDAS scores did not change for migraineurs who added barbiturates or opioids to triptan therapy, regardless of headache frequency.
“On average, switching from one triptan to another or adding a second triptan is not helpful,” commented Dr. Lipton. “That is not to say that when we switch individual patients, there isn’t a benefit to that, or that optimized algorithms for choosing treatments have no effect on patient care.”
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Bigal ME, Serrano D, Buse D, et al. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache. 2008;48(8):1157-1168.
Chu MK, Buse DC, Bigal ME, et al. Factors associated with triptan use in episodic migraine: results from the American Migraine Prevalence and Prevention Study. Headache. 2012;52(2):213-23.