Review of Treatment Strategies for Successful Migraine Management
Pain is the most common reason for consultation with primary care physicians, and the most common pain types evaluated are back pain and headaches. Migraine headache is a common complaint, with a higher incidence reported by females. It is estimated that 6% of men and 18% of women currently suffer from this disease. However, the prevalence of migraine headache is probably higher, according to the results of the American Migraine Study. Study results indicated that 71% of men and 59% of women were determined to have migraine headaches from self-reported symptoms but they never received a formal diagnosis.
An accurate estimate of the economic impact of migraine headaches has been difficult to obtain. However, most of the studies attribute the large economic burden to costs associated with disability, decreased functional status, and the consequent indirect costs to employers. A recent study by Stewart al. indicated that the average number of migraine attacks per year was 34 for men and 37.4 for women, and 58% of patients needed some bed rest during the attack. Moreover, the study indicated that the annual treatment costs in the U.S. are over one billion health care dollars, 80% of which were spent treating female patients. Physician-office-related expenses accounted for 60% of the total cost and prescription drugs accounted for 30%. Notable is the low cost of emergency department treatment for migraine headache, which accounted for less than 1% of the total cost.3 The indirect cost to American employers was estimated at $13 billion annually. It is important to note that several components that were needed to calculate burden-of-disease estimates were missing from this study, such as the value of lost homeworker tasks; missing work to take care of a family member with a migraine; and decreased involvement in family, social, and leisure activities. erectalis 20
The aforementioned study and several others indicate that the cost of migraine headache to society is large and comparable to other costly chronic diseases, such as diabetes and asthma. Several treatment options are now available for migraine headache; however, effective management must incorporate a multidisciplinary approach and remains challenging. Evidence-based multispecialty consensus has been recently developed by the U.S. Headache Consortium in an effort to enhance the care of migraine patients. This article will provide an overview of the pharmacological agents used in migraine management, including the recommendations from the U.S. Headache Consortium,7 with a focus on the use and safety of the triptans in the acute management of migraine attacks.
Pathophysiology of Migraine Headaches
Thus far, no single theory can completely explain the etiology of migraine headaches, and probably most (if not all) current theories are interrelated. Neurotransmitters, including serotonin, adrenergic, dopamine, and histamine, have been implicated, and play an important role in the etiology of migraine. Serotonin (5-hydroxytriptamine, 5-HT) has been the center of interest for investigators; to date, seven classes of serotonin receptors have been identified. The 5-HT1 and 5-HT2 receptors are believed to be associated with migraine headache pathogenesis because activation of 5-HT1 receptors leads to effective symptomatic relief and because inhibition of 5-HT2 receptors results in prophylaxis of migraine attacks.
Based on our current understanding of the pathophysiology of migraine headache, there are at least three target mechanisms that can achieve efficacy and pain relief: (1) the reversal of cranial blood-vessel dilation, (2) inhibition of activated peripheral trigeminal nerve terminals, and (3) reduction in neuronal activity in central trigeminal neurons. The distribution and function of serotonin receptors throughout the body has been advanced by molecular biology and immunohistochemical research, which in part helped explain the efficacy and adverse effect profile observed with the 5-HT1B1D agonists. Wide 5-HT1B receptor expression has been located in the smooth muscle of meningeal blood vessels, which cause vaso-constriction when stimulated. However, this receptor type has also been found in coronary arteries. The serotonin 5-ШГщ subtype is expressed on both the peripheral and central terminals of the trigeminal nerve fibers arising from these cells. Moreover, this receptor subtype is extensively localized to the nucleus of the tractus solitarium, which mediates nausea and vomiting associated with central pain transmission. Viagra Online Canadian Pharmacy
The majority of current abortive therapies for migraine headache act primarily on serotonin receptors, including ergot derivatives and 5-HT 1B/1D agonists. Ergot derivatives, moreover, affect dopamine and a-adren-ergic receptors. Other therapies, such as antihistamines and phenothiazines, have documented efficacy in the acute treatment of migraine headache through histamine blockade and actions at the dopamine receptors.
Principles of Treatment
General treatment principles of migraine management include establishing a diagnosis, establishing realistic patient expectations, encouraging the patient to identify and avoid triggers, and creating a formal, individualized management plan. A study conducted by Lipton and Stewart echoed the importance of creating a treatment plan after the physician gains insight into what the patient wants. If the patient’s and doctor’s expectations, treatment goals, and preferences are not mutually identified, then a lack of compliance can occur—possibly resulting in worse treat ment outcomes.
Table 1 Levels of Evidence for Treatment Recommendations
| Level I. Independent, blind comparison with a “gold standard” of anatomy, physiology, diagnosis, or prognosis among a large number of consecutive patients suspected of having the target condition.
Level II. Independent, blind comparison with a “gold standard” among a small number of consecutive patients suspected of having the target condition. Level III. Independent, blind comparison with a “gold standard” among nonconsecutive patients suspected of having the target condition. Level IV. Included studies that did not meet criteria for at least level III evidence. |
| Strength of evidence (quality of evidence) |
| Grade A. Multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings.
Grade B.Some evidence from randomized clinical trials supported the recommendation, but the scientific support was not optimal. For instance, few randomized trials existed, the trials that did exist were somewhat inconsistent, or the trials were not directly relevant to the recommendation. An example of the last point would be the case where trials were conducted using a study group that differed from the target group of the recommendation. Grade C. The U.S. Headache Consortium achieved a consensus on the recommendation in the absence of relevant randomized controlled trials. |
| Scientific effect measures |
|
0 The medication is ineffective or harmful. + The effect of the medication is either not statistically or not clinically significant. ++ The effect of the medication is statistically significant and exceeds the minimally clinically significant benefit. +++ The effect is statistically significant and far exceeds the minimally clinically significant benefit. |
| Clinical impression of effect |
|
0 Ineffective: most people get no improvement. + Somewhat effective; few people get clinically significant improvement. ++ Effective: some people get clinically significant improvement. +++ Very effective: most people get clinically significant improvement. |
| Adapted from the U.S. Headache Consortium Guidelines for Preventive Therapy. |
Recently, the U.S. Headache Consortium, which is made up of a multi-disciplinary panel of professional organizations, released evidence-based guidelines for migraine headache management (Table 1). The main goal was to establish treatment guidelines in four distinct areas of migraine management: diagnostic testing, pharmacologic management of acute attacks, preventive therapy, and behavioral and physical treatments of migraine. buy antibiotics without prescription
