The U.S. Headache Consortium guidelines on the pharmacologic management of acute migraine emphasize the need for physicians and patients to work together to decide how to treat acute attacks. The panel members identified six goals for the long-term treatment of migraine: (1) reduce the frequency and severity of attacks; (2) reduce disability from the attacks; (3) improve the patient's quality of life; (4) prevent headache; (5) avoid escalation of medication used to treat migraine; and (6) educate patients and enable them to manage their headaches. The panel members also identified six goals for the treatment of acute attacks: (1) treat the attacks rapidly and consistently and eliminate recurrence of the attack; (2) restore the patient's ability to function; (3) minimize the use of backup and rescue medications; (4) optimize self-care and reduce subsequent use of resources; (5) institute cost-effective approaches for overall management; and (6) minimize or avoid adverse events. The guidelines are available at the American Academy of Neurology Web site (http://www.neurology.org) and at the American Academy of Family Physicians Web site (https://www.aafp.org).
To develop evidence-based recommendations for the pharmacologic treatment of acute migraine attacks, members of the headache consortium reviewed the migraine guidelines of the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) as well as an analysis by the Duke University Center for Clinical Health Policy Research, Durham, N.C. Panel members analyzed data from many clinical studies of drugs used to treat acute migraine, including antiemetics, barbiturate hypnotics, ergot alkaloids and derivatives, nonsteroidal anti-inflammatory drugs (NSAIDs), combination analgesics, nonopiate analgesics, opiate analgesics and serotonin 5-HT agonists (i.e., the “triptans”). The accompanying table on page 1916 provides a breakdown of the various drugs used in the treatment of acute migraine and the strength of the evidence for their use. A summary of the headache consortium's recommendations for individual drugs will be published in the next issue of American Family Physician.
General Principles of Management
The U.S. Headache Consortium identified two general principles of care for patients with migraine: (1) involve patients in their own management, such as discussing preferences for treatment, and (2) tailor treatment to the individual patient's needs, such as according to the severity of the migraines, comorbidity, coexisting conditions and previous response to medications.
Five general recommendations for the treatment of acute migraine were formulated by the headache consortium:
Educate patients with migraine about their condition and its treatment and encourage them to participate in their own management. According to the guidelines, the patient's input can provide the best guide to the selection of treatment, in part because patients differ in their response to individual agents. In addition, by obtaining the patient's input, the physician can better understand and accommodate the patient's goals of treatment. Because strategies for treating acute migraine attacks can be complex, the patient is more likely to achieve success if he or she is engaged in developing the treatment plan.
Use migraine-specific agents in patients with more severe migraine and in those whose headaches respond poorly to NSAIDs or combination analgesics such as aspirin plus acetaminophen plus caffeine. The consortium members believe that clinical experience strongly indicates that headaches of different types and severity respond to specific agents, even though no data support this impression.
Select a nonoral route of administration for patients whose migraines are characterized by nausea or vomiting early in the course of an attack. The guidelines state that an antiemetic should not be limited to patients who have vomiting or who are likely to vomit because nausea is one of the most disabling symptoms of a migraine attack. The combination of an antiemetic and an oral migraine drug may be appropriate in some patients.
Consider use of a self-administered rescue medication for patients with severe migraines that fail to respond well to other treatments. A rescue medication is used at home when other migraine treatments fail to provide relief. While a rescue medication may not completely eliminate the pain, it can provide relief and obviate the need for the patient to visit the physician's office or the emergency department.
Guard against medication-overuse headache. Medication-overuse headache, sometimes referred to as “rebound headache” or “drug-induced headache,” is characterized by an increased frequency in the headaches, to as often as daily. The guidelines state that rebound headache is different from medication-overuse headache. Rebound headache is associated with withdrawal of analgesics or of medications used to abort migraine attacks. The consortium found that there is no agreement concerning which agents can cause rebound headache. In general, this phenomenon is thought to occur with ergotamine, opiates, serotonin 5-HT agonists, NSAIDs and analgesics containing butalbital, caffeine or isometheptene. To decrease the risk of medication-overuse headaches, the consortium members point out that many experts suggest that acute therapy be reserved for those patients who regularly have two or more headache days per week. Preventive therapy may be considered in patients suspected of medication overuse or at risk of overuse.
Questions to Be Answered by Future Research
The U.S. Headache Consortium identified a number of aspects of migraine treatment that require research. For example, among the unanswered questions are whether it is effective to target therapy to headache severity and whether early aggressive therapy provides significant benefit in less severe migraine or migraine prodrome. Studies are also needed to identify the etiology of headache recurrence and measures that can be taken to avoid it and to treat it. Research is also needed to identify any factors, including specific agents and dosages, that may increase the susceptibility to rebound headache. While rescue medications are often used in the management of migraine, clinical studies are needed to clarify which patients are likely to benefit from this approach.
With regard to specific agents used in the treatment of migraine, the consortium members found that long-term studies are needed to evaluate the efficacy of opiate analgesics in reducing the frequency, severity and duration of migraine attacks. They also found that no randomized, placebo-controlled trials have been performed to evaluate the efficacy of butalbital-containing analgesics in the treatment of migraine, despite their widespread use.