Differentiating between migraine treatments
PHILADELPHIA — There are perhaps more acute, prophylactic and nonmedicinal treatments for patients with migraine than ever before, according to a speaker at the American College of Physicians Internal Medicine Meeting.
Migraine impacts about 10% of the U.S. population, or nearly one in four U.S. households, according to the Migraine Research Foundation.
“There is no more grateful patient than a headache patient that you have helped feel better and given them some of their life back,” Michael Cutrer, MD, neurologist at the Mayo Clinic, told attendees.
“Fortunately, as time as gone on, there are more and more potentially effective treatments for these patients,” he said.
Cutrer said acute migraine treatments usually work best in those utilizing them on an “as needed” basis.
“Make sure your patients have a multilayered plan for the different levels of acute treatment and that they know when to implement each level. If they catch the migraine early on, they will likely respond to a lower dose of their medication,” he said.
Options for mild-to-moderate acute migraine include acetaminophen, NSAIDs or isometheptene mucate. Choices for moderate-to-severe acute migraine include ergotamines, sumatriptan, naratriptan, eletriptan, almotriptan, rizatriptan and zolmitriptan pills, or ketorolac, chlorpromazine, droperidol or valproate injections.
Patients should titrate up to stronger doses of these medications, Cutrer said.
“I advise patients to use NSAIDs first, so they can ‘save’ the more aggressive triptan for when it is really needed. I also don’t favor using triptans more than 3 days per week, and would advise against using combination analgesics, especially those that contain caffeine.”
Other acute migraine treatment options include greater and lesser occipital nerve blocks, supraorbital and supratrochlear blocks, sphenopalatine ganglion blocks. A newer addition to this market is transcranial magnetic stimulation, Cutrer said.
“This device may scramble or stop the aura in migraine, is said to be benign and rentable for various periods of time. Though it’s not cheap, it does sometimes provide really good relief,” he said.
Patients who fear the onset of a migraine attack, have attacks that impact their normal range of activities, have contraindicated or ineffective acute treatments, prolonged neurological symptoms and/or a history of migrainous infarction, are among those who would benefit from prophylactic treatment, Cutrer said.
Prophylactic options include botulinum toxin injections and calcitonin gene-related peptide blockers such as Ajovy (fremanezumab-vfrm, Teva) and Aimovig (erenumab-aooe; Amgen, Novartis) as well as Cefaly supraorbital nerve stimulator; vagal nerve stimulator; lifestyle adjustment and behavioral techniques and the previously mentioned transcranial magnetic stimulation, he said.
“There is no evidence to suggest one of these treatments is better than the other. Therapy selection is usually based on patient response,” and, where possible, when it can simultaneously help treat another condition," Cutrer said.
He also noted that a wider range of migraine treatments have allowed some flexibility in assisting patients who hinge on the border between needing acute and prophylactic treatments, according to Cutrer.
“For years, the dogma was to prescribe prophylactic treatments in patients who had three or more migraine headache attacks per month or 2 more days per week. But with all the advances we have made, if a patient crosses those levels, he or she is on the slippery slope to medication overuse.”
“In other words, if you have a patient with one migraine a week and their triptan is providing an adequate response, live and let live until they cross that boundary where the triptan does not work, then consider a prophylactic treatment,” Cutrer said.
Patients who should use treatments without medicine include pregnant patients, and those who are hesitant to take medications, are poorly tolerant of or have contraindications to other treatments, and/or have shown “poor response” to drug treatment, according to Cutrer.
He added the nonmedicinal approaches with the “best evidence” of working are relaxation therapy, thermal biofeedback with relaxation training, EMG biofeedback and cognitive behavioral therapy. – by Janel Miller
References: Cutrer M. “What internists need to know about diagnosing and managing headaches: Taking the “ache” out of headache.” Presented at: American College of Physicians Internal Medicine Meeting; April 11-13, 2019; Philadelphia.
Migraine Research Foundation. “About migraine.” https://migraineresearchfoundation.org/about-migraine/migraine-facts/. Accessed April 15, 2019.
Disclosures: Cutrer reports serving as an advisory board member for Alder Pharmaceuticals.