For Best Results, Consider Migraine Complex

SCOTTSDALE, ARIZ. – Acute migraine cannot be managed effectively without a therapeutic partnership between doctor and patient, and a full understanding of the disabling features of each patient's headache episodes, Dr. Lawrence C. Newman said.

“Most of us are focused on the head pain, but when you talk to patients, many [of them] will say they are not disabled by the head pain as much as they are by some of the migraine-associated features such as nausea and vomiting. So by focusing on the head pain, you're not truly helping that individual,” Dr. Newman said at a symposium sponsored by the American Headache Society.

It's important to consider the entire migraine complex, to treat pain and associated symptoms using the stratified care approach, and to specifically ask patients about disability, said Dr. Newman, who is director of the Roosevelt Headache Institute in New York City.

“All too often we get a history that says the patient is getting, for example, two headaches a month and we leave it at that and give him medications to take on those 2 days acutely, but if you delve a bit more into that history, you'll see that one of those attacks is so severe that the patient isn't going to work regularly,” he said.

Dr. Newman said his colleagues must make sure they know what medications each patient has taken in the past, what the dosages were, what has or has not worked, and how frequently the attacks occur.

Once a correct migraine diagnosis is made, therapy can be undertaken based on the disability that the headaches generate, said Dr. Newman, who explained that stratified care based on disability has been shown to be superior to step care (JAMA 2000;284:2599–605).

“Using the MIDAS [Migraine Disability Assessment] Questionnaire, stratify the patient into a low-need group (MIDAS score 0–5), a moderate-need group (6–10), or a high-need group (11+),” he said. “Again, you have to specifically ask the patient about the disability caused by her headaches.

“For those [patients] with a low need, start with an NSAID or other nonspecific agent. If it doesn't work, then step up the care to a specific agent for migraine.

“But as the disability increases, you're more apt to target right away using a specific agent, whether it's a triptan or a dihydroergotamine or ergotamine tartrate, and in the upper stages you need to consider placing the patient on prophylactic therapy as well,” Dr. Newman explained.

Unlike preventive medications, which are started at low doses, Dr. Newman explained that medications for acute migraine are useful when started at higher doses, and decreased if there is a tolerability issue. “The reason I say that is that all too often patients are put on a low dose, they come back saying it doesn't work, and they will not go back on what was potentially a useful medication.”

Dr. Newman said in studies of acute migraine treatment, especially those involving triptans, patients on higher doses had better therapeutic responses than those on lower doses, but did not have more adverse events.

Nor should physicians worry about early use of short-term medications leading to overuse. “In fact, those patients who treat their attacks early are much more likely to take one tablet, or one injection, or one nasal spray, be done with their headache and not have to take more medication,” he said.

To increase the effectiveness of treatment, medicate early and at the appropriate dose. “If necessary, increase the dose, or add adjuvants such as metoclopramide or an NSAID, which can increase the effectiveness of the acute medication,” Dr. Newman said.

Similarly, if the first triptan doesn't work, don't hesitate to try a different drug in the same class. “The good news is that among patients who don't respond to a specific triptan, about half of them will respond to a different triptan,” Dr. Newman said, adding that it's important to be aware of drug interactions and co-occurring conditions such as hypertension/hypotension, angina, ulcer disease, vertigo, asthma, and allergies.

Dr. Newman declared relationships with Allergan, Endo Pharmaceuticals, Pfizer Inc., Merck & Co., and Ortho-McNeil Inc., as a consultant and/or member of the advisory board or speakers' bureau.

SCOTTSDALE, ARIZ. – Acute migraine cannot be managed effectively without a therapeutic partnership between doctor and patient, and a full understanding of the disabling features of each patient's headache episodes, Dr. Lawrence C. Newman said.

“Most of us are focused on the head pain, but when you talk to patients, many [of them] will say they are not disabled by the head pain as much as they are by some of the migraine-associated features such as nausea and vomiting. So by focusing on the head pain, you're not truly helping that individual,” Dr. Newman said at a symposium sponsored by the American Headache Society.

It's important to consider the entire migraine complex, to treat pain and associated symptoms using the stratified care approach, and to specifically ask patients about disability, said Dr. Newman, who is director of the Roosevelt Headache Institute in New York City.

“All too often we get a history that says the patient is getting, for example, two headaches a month and we leave it at that and give him medications to take on those 2 days acutely, but if you delve a bit more into that history, you'll see that one of those attacks is so severe that the patient isn't going to work regularly,” he said.

Dr. Newman said his colleagues must make sure they know what medications each patient has taken in the past, what the dosages were, what has or has not worked, and how frequently the attacks occur.

Once a correct migraine diagnosis is made, therapy can be undertaken based on the disability that the headaches generate, said Dr. Newman, who explained that stratified care based on disability has been shown to be superior to step care (JAMA 2000;284:2599–605).

“Using the MIDAS [Migraine Disability Assessment] Questionnaire, stratify the patient into a low-need group (MIDAS score 0–5), a moderate-need group (6–10), or a high-need group (11+),” he said. “Again, you have to specifically ask the patient about the disability caused by her headaches.

“For those [patients] with a low need, start with an NSAID or other nonspecific agent. If it doesn't work, then step up the care to a specific agent for migraine.

“But as the disability increases, you're more apt to target right away using a specific agent, whether it's a triptan or a dihydroergotamine or ergotamine tartrate, and in the upper stages you need to consider placing the patient on prophylactic therapy as well,” Dr. Newman explained.

Unlike preventive medications, which are started at low doses, Dr. Newman explained that medications for acute migraine are useful when started at higher doses, and decreased if there is a tolerability issue. “The reason I say that is that all too often patients are put on a low dose, they come back saying it doesn't work, and they will not go back on what was potentially a useful medication.”

Dr. Newman said in studies of acute migraine treatment, especially those involving triptans, patients on higher doses had better therapeutic responses than those on lower doses, but did not have more adverse events.

Nor should physicians worry about early use of short-term medications leading to overuse. “In fact, those patients who treat their attacks early are much more likely to take one tablet, or one injection, or one nasal spray, be done with their headache and not have to take more medication,” he said.

To increase the effectiveness of treatment, medicate early and at the appropriate dose. “If necessary, increase the dose, or add adjuvants such as metoclopramide or an NSAID, which can increase the effectiveness of the acute medication,” Dr. Newman said.

Similarly, if the first triptan doesn't work, don't hesitate to try a different drug in the same class. “The good news is that among patients who don't respond to a specific triptan, about half of them will respond to a different triptan,” Dr. Newman said, adding that it's important to be aware of drug interactions and co-occurring conditions such as hypertension/hypotension, angina, ulcer disease, vertigo, asthma, and allergies.

Dr. Newman declared relationships with Allergan, Endo Pharmaceuticals, Pfizer Inc., Merck & Co., and Ortho-McNeil Inc., as a consultant and/or member of the advisory board or speakers' bureau.

SCOTTSDALE, ARIZ. – Acute migraine cannot be managed effectively without a therapeutic partnership between doctor and patient, and a full understanding of the disabling features of each patient's headache episodes, Dr. Lawrence C. Newman said.

“Most of us are focused on the head pain, but when you talk to patients, many [of them] will say they are not disabled by the head pain as much as they are by some of the migraine-associated features such as nausea and vomiting. So by focusing on the head pain, you're not truly helping that individual,” Dr. Newman said at a symposium sponsored by the American Headache Society.

It's important to consider the entire migraine complex, to treat pain and associated symptoms using the stratified care approach, and to specifically ask patients about disability, said Dr. Newman, who is director of the Roosevelt Headache Institute in New York City.

“All too often we get a history that says the patient is getting, for example, two headaches a month and we leave it at that and give him medications to take on those 2 days acutely, but if you delve a bit more into that history, you'll see that one of those attacks is so severe that the patient isn't going to work regularly,” he said.

Dr. Newman said his colleagues must make sure they know what medications each patient has taken in the past, what the dosages were, what has or has not worked, and how frequently the attacks occur.

Once a correct migraine diagnosis is made, therapy can be undertaken based on the disability that the headaches generate, said Dr. Newman, who explained that stratified care based on disability has been shown to be superior to step care (JAMA 2000;284:2599–605).

“Using the MIDAS [Migraine Disability Assessment] Questionnaire, stratify the patient into a low-need group (MIDAS score 0–5), a moderate-need group (6–10), or a high-need group (11+),” he said. “Again, you have to specifically ask the patient about the disability caused by her headaches.

“For those [patients] with a low need, start with an NSAID or other nonspecific agent. If it doesn't work, then step up the care to a specific agent for migraine.

“But as the disability increases, you're more apt to target right away using a specific agent, whether it's a triptan or a dihydroergotamine or ergotamine tartrate, and in the upper stages you need to consider placing the patient on prophylactic therapy as well,” Dr. Newman explained.

Unlike preventive medications, which are started at low doses, Dr. Newman explained that medications for acute migraine are useful when started at higher doses, and decreased if there is a tolerability issue. “The reason I say that is that all too often patients are put on a low dose, they come back saying it doesn't work, and they will not go back on what was potentially a useful medication.”

Dr. Newman said in studies of acute migraine treatment, especially those involving triptans, patients on higher doses had better therapeutic responses than those on lower doses, but did not have more adverse events.

Nor should physicians worry about early use of short-term medications leading to overuse. “In fact, those patients who treat their attacks early are much more likely to take one tablet, or one injection, or one nasal spray, be done with their headache and not have to take more medication,” he said.

To increase the effectiveness of treatment, medicate early and at the appropriate dose. “If necessary, increase the dose, or add adjuvants such as metoclopramide or an NSAID, which can increase the effectiveness of the acute medication,” Dr. Newman said.

Similarly, if the first triptan doesn't work, don't hesitate to try a different drug in the same class. “The good news is that among patients who don't respond to a specific triptan, about half of them will respond to a different triptan,” Dr. Newman said, adding that it's important to be aware of drug interactions and co-occurring conditions such as hypertension/hypotension, angina, ulcer disease, vertigo, asthma, and allergies.

Dr. Newman declared relationships with Allergan, Endo Pharmaceuticals, Pfizer Inc., Merck & Co., and Ortho-McNeil Inc., as a consultant and/or member of the advisory board or speakers' bureau.