Review of Treatment Strategies for Successful Migraine Management: TREATMENT STRATEGIES
Early Treatment of Migraine Attacks
More recently, evidence indicates that early pharmacologic intervention during a migraine attack could provide higher levels of pain relief than later intervention. Retrospective post-hoc analysis of the Spectrum Study results was performed in patients with disabling headaches who were treated while the pain was mild. Results suggest that 50 mg of sumatrip-tan (Imitrex tablet, Glaxo Wellcome Inc) was more effective than placebo for early treatment of migraine attacks. Moreover, pain-free rates were higher for attacks treated with a 50-mg sumatriptan tablet compared to placebo at two and four hours post-dose when pain was rated mild. Currently, no comparable, randomized, placebo-controlled trials support or refute this finding. This observation was not the primary endpoint of the study and, therefore, merits further investigation. Similar findings were reported by the International 311C90 Long-Term Study Group. Also of interest was the lower incidence of adverse effects reported in patients using 50-mg suma-triptan tablets when pain was mild as compared to patients who medicated when pain was moderate to severe. In part, this might be caused by a heightened sensory sensitivity during a migraine attack when pain is moderate to severe. Patients might have an improved tolerance to medications if they treat the migraine attack early, before the occurrence of heightened sensitivity; however, this needs further investigation.
Stratified Care Versus Step Care
Many treatment strategies exist in the medical community for dealing with the acute treatment of headache disorders. Strategies that have received a great deal of attention recently are the post-hoc analysis of the Spectrum Study, which was discussed earlier, and stratified versus step care. Stratifiedcare involves the use of agents based on the presenting severity of the illness. The Migraine Disability Assessment Scale (MIDAS) is a tool that has been extensively validated and is often used to assess disability resulting from a migraine attack. Step care involves the use of agents in an escalating fashion after the failure of initial treatments. Simple analgesics are usually used initially, followed by isometheptene-containing agents, followed by triptans. A recent randomized trial, The Disability in Strategies of Care (DISC) Study, was completed to evaluate the difference in efficacy, if any, between these treatment plans. This study was conducted in a randomized, parallel-group, open-label fashion and compared stratified care and step care within attacks, and step care across attacks. Results of the study demonstrated that patients achieved better outcomes with stratified care than with step care, within and across attacks. It is important to remember that this study randomized patients to a treatment strategy and not to a specific drug therapy. Step care is often the treatment strategy used in clinical practice, and a delay in administering an effective treatment might be problematic. As a consequence of this treatment strategy, a greater degree of disability from the migraine attack could occur; patients might then become frustrated and not follow up for medical treatment, or they might seek more acute care in the ER setting, which is more costly.
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More studies need to be completed to assess treatment strategies and to validate the results reported from the DISC trial and the post-hoc analysis of the Spectrum study. Some clinicians might discourage early treatment of attacks because some attacks do not progress in intensity or they might resolve. Other clinicians do not use triptans for mild pain because of their expense; they use other, less expensive alternatives. Numerous studies, mainly with sumatriptan, demonstrated the cost-effectiveness of the triptans in the treatment of migraine attacks by a reduction in productivity loss. Other studies reported that, after the use of sumatriptan canadian, they observed a decrease in clinic utilization rate, costs of care, and a loss of productivity, along with an increase in quality-of-life indicators.
