Return to function, pain reduction primary goals of acute migraine treatment

LAS VEGAS — Rapid reduction of symptoms and pain, achieved through the most effective drug and nondrug treatments, is a key priority for patients who experience acute migraines, according to a presenter at BRAINWeek 2022.

“The most important thing for patients is a return to function,” Merle Diamond, MD, of the Diamond Headache Clinic, said during her presentation. “A good rule of thumb when I talk to my patients about acute therapy ... is what percentage of the time do you think this medicine works for you? And if a patient says 50%, it’s not a great acute medicine.”

For acute treatment, as opposed to prevention, there is less discord between patient and physician regarding treatment goals, Diamond stated. Patients with acute migraines require medication that works, at minimum, 80% to 90% of the time, and 90% of patients take oral therapeutics but need to attack their migraine pain earlier in the cycle to achieve rapid onset of pain freedom. That, Diamond added, requires medications with established efficacy to be beneficial in both the short and long term.

According to Diamond, NSAIDs, such as ibuprofen and naproxen, are the first line of defense for acute migraines. Next are combination analgesics, such as acetaminophen with aspirin and caffeine, then triptans (almotriptan, eletriptan, zolmitriptan) in varying doses, ergotamine derivatives (dihydroergotamine nasal spray), gepants (rimegepant, Ubrelvy [ubrogepant, AbbVie]) and Reyvow (lasmiditan, Eli Lilly and Co.).

Diamond cited the National Headache Foundation’s (NHF’s) modified step-care model for acute migraine treatment, which seeks to optimize time to pain-free and functional status and states that a patient needs to have experienced moderate to severe pain related to migraines and to have “tried and been failed by” two generic drugs before a physician can prescribe next-level treatments.

Per NHF guidelines, a “failed” treatment includes at least one of the following: the patient is not migraine pain-free and functional within 2 hours of treatment after the majority of attacks or the patient has recurrence of migraine symptoms within 24 hours after treatment; the patient cannot tolerate the drug due to its side effects; the patient has a recorded history of the drug being proved ineffective or intolerable; or the patient has a comorbidity and/or other contraindication that precludes the clinician from prescribing the drug.

Common difficulties associated with acute treatments are underdosing, delayed dose delivery and failure to include cooperative agents with triptans, Diamond said. An associated miscue, she noted, is that patients often try to adjust dosage based on time and severity of migraine symptoms.

“There’s no clinical value to the notion that if you try something at a different dose, either higher or lower, that there’s no risk of something [bad] happening,” Diamond stated.

However, there is no rule against combining certain therapies to achieve maximum effectiveness, she continued.

One of the newer therapies to address acute migraine symptoms is neuromodulation, which can be performed in several ways: supraorbital transcutaneous nerve stimulation, vagal nerve stimulation and single pulse transcranial nerve stimulation.

These options, according to Diamond, should be considered after multiple traditional drugs and newer treatments have failed, in cases of overuse of standard treatments, in adults who prefer nondrug therapies and in pediatric patients.

None of these options, Diamond said, can really be of service unless patients are diligent in keeping a detailed, consistent and continual headache diary. By doing so, patients and clinicians can have a clear picture of symptoms and can enact an effective, immediate and flexible treatment plan.

“I think it’s super supportive to hear the patient when they say they’re doing well,” Diamond said.