Optimizing the Acute Treatment of Migraine Brian M. Plato, DO, FAHS Norton Neuroscience Institute Louisville, KY Disclosures Speakers Bureau (personal): Allergan, Depomed, Avanir Research Funding (paid to my employer): Allergan, Alder, Teva, ATI The best defense is a good offense 1
Patients want better treatment Survey at specialty headache clinic: 57% of patients had to re-dose their acute medication 28% had to dose a third time While 66% reported being very satisfied / satisfied; 88% reported that they would be willing to try a new antimigraine medication Malik SN, Hopkins M, Young WB, Silberstein SD. Acute migraine treatment: patterns of use and satisfaction in a clinical population. Headache. 2006;46(5):773-80. Patients DESERVE better treatment We know that some patients with episodic migraine will transform to chronic migraine It is our jobs to try to help these patients avoid progressing to CM Risk factors include: Overuse of acute medications Ineffective acute medication use Katsarava Z, Schneeweiss S, Kurth T, et al. Incidence and predictors for chronicity of headache in patients with episodic migraine. Neurology 2004;62(5):788-90. Put the fire out, don t just control it 2
Road blocks to optimal acute treatment? Patients Delayed treatment Lack of access to better / migraine specific medications Abundance of less effective OTC options Lack of recognition of frequency of use (diaries are helpful here) Side effects Hope Maybe this OTC will work Us Insurance coverage See Mia Minen spaper on this in Headache Not educating patients Limited tools available Not asking the right questions (patients take a LOT of OTC meds) Getting stuck thinking about preventive treatment Approaches to Acute Treatment of Migraine Stratified care approach Medication is chosen based upon the characteristics of the specific attack If this then that Step care approach Patients start with one medication and then if not having relief another medication is used i.e starting with simple analgesic followed by triptan Problem is that as time develops second medication may be less effective Comparing the two (JAMA 2000;284(20):2599-2605) Stratified care patients were more likely to have headache response at 2 hours Principles of Acute Migraine Treatment Treat early Educate patients (they already know this but maybe have not verbalized it) that not all attacks are created equally and as such choose the most appropriate option for the specific attack Wake-up migraine Vomiting Quickly developing migraine At work vs at home Use multiple medications with different mechanisms in combination Use other routes of administration (oral vs injectable vs nasal vs suppository) Monitor for the development of MOH and re-evaluate with each visit Ask How effective is medication X? Are you satisfied with X? Be your patient s cheerleader remind them that there are other options and you may need to modify treatment regimen based upon tolerability vs efficacy 3
Medication choices NSAIDs Antiemetics Triptans DHE Butalbital containing medications Opioids Patient preferences need to be considered Do they have an aversion to pills (sometimes in younger patients)? Will not use an injection? Don t like nasal sprays? Won t use a suppository? A prescription you give that they won t use has a 0% pain-free response at 2 hours 4
NSAIDs Oral tablet / liquid capsules are appropriate for milder, slower developing attacks without significant nausea For more severe attacks or those with nausea consider: Diclofenac potassium for oral solution Indomethacin suppository* Ketorolac IM* Ketorolac NS* *Not FDA approved for acute treatment of migraine Antiemetics Metoclopramide* 5-10mg PO Prochlorperazine* 5-10mg PO 25mg suppository Can be a very nice adjunctive medication to an NSAID/triptan/DHE Often times are sedating (sometimes a good thing) *Not FDA approved for acute treatment of migraine Triptans Unless there are contraindications, should be the mainstay of treatment for moderate / severe attacks 7 different triptans to choose from Depending upon the characteristics of the attack and patient s response / side effects might consider quicker acting vs slower acting Differing routes of administration to consider Oral tablets Orally dissolving tablets Nasal spray (liquid) Nasal powder Injectable 5
Have several options available Oral triptanfor moderate attacks or those developing slower without nausea Nasal for those that are moderate with nausea Injectable for severe attacks or those with vomiting Can use a different preparation of the same product as a rescue Take oral sumatriptanat onset; if not improved or worsening follow-up with injectable sumatriptan Need to be cautious about mixing different triptans Triptans + Combining triptans with other classes of drug may be helpful Patients who used sumatriptan + metoclopramide had better headache relief with the combination Sumatriptan + naproxen found to have better response rates than either drug individually (quick acting triptan + long acting NSAID) Frovatriptan + dexketoprofen had higher pain-free rates than frovatriptan alone (long acting triptan + quick acting NSAID) Schulman EA, Dermott KF. Sumatriptanplus metoclopramide in triptan-nonresponsive migraineurs. Headache 2003;43(7):729-733. BrandesJL, Kudrow D, Stark SR, et al. Sumatriptan-naproxen for acute treatment of migraine: a randomized trial. JAMA 2007;297(13):1443-1454. Tullo V, ValguarneraF, BarbantiP, et al. Comparison of frovatriptanplus dexketoprofen (25 mg or 37.5 mg) with frovatriptanalone in the treatment of migraine attacks with or without aura: a randomized study. Cephalalgia2014;34(6):434-445. DHE For patients who do not respond to triptans, DHE is a reasonable option for acute treatment The longer half-life (9 hours) is useful for patients who have higher rates of recurrence with triptans Available in nasal spray Or available for IM injection Not to be used within 24 hours of triptanuse 6
What to (try to) avoid Butalbital containing medications Opioid containing medications Higher rates of medication overuse headache Limited evidence for effectiveness There are some patients who respond to limited doses of these medications Monitor for escalating doses Monitor for increasing frequency of headache Teaching patients how to give an IM injection Clues that things aren t going well Frequent phone calls / visits Frequent refill requests While you may try to limit the number of triptans that patients receive per month, their insurance may allow them to refill more than once per month They may cash pay (sumatriptan generic on GoodRx.com=$12.40 for 9 pills) Escalating frequency of headache Diaries can be very helpful in these situations Patients who have headache for multiple days in a row 7
When things are failing Make sure that they know how to use the medications Make sure that they know when to use the medications Ask why they don t use their medications? Do they have side effects? Are they too expensive? Are they ineffective? Start over Personally, sometimes I get stuck in a rut Do a new consultation start from the beginning with them Questions? brian.plato@nortonhealthcare.org 8
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