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To provide an overview of the objectives and target population of the guideline, and to review the general principles of acute pharmacological migraine therapy.
A general literature review and several consensus groups were used to formulate an expert consensus for the general use of acute migraine medications.
The objective of the guideline is to assist the physician in choosing an appropriate acute migraine medication for an individual with migraine, and thereby to reduce migraine-related disability. The target population includes adults with episodic migraine (patients with migraine headache < 15 days/month). This guideline is intended primarily for physicians who treat patients with migraine. Other health professionals may also find this guideline helpful. Acute migraine therapy should be considered for the great majority of patients with migraine. A specific acute medication is chosen based on evidence for efficacy, tolerability, migraine attack severity, patient preference, and on the presence of co-existing disorders. General principles of acute migraine therapy include that the response of a patient to any given medication cannot be predicted with certainty, and that treatment early in the attack is generally more effective than treatment later once the migraine attack is fully developed. A suitable treatment approach (stratified or stepped approaches) and drug formulation (injection, tablet, wafer, powdered formulation, or nasal spray) should be chosen based on patient clinical features. Excessively frequent use of acute medications (medication overuse) should be avoided. Two or more acute medications can be combined if necessary.
This guideline provides evidence-based advice on the use of acute medications for migraine, and should provide useful guidance for acute migraine therapy to both health professionals and patients.
To assess the evidence base for drugs used for acute treatment of episodic migraine (headache on < 14 days a month) in Canada.
A detailed search strategy was employed to find relevant published clinical trials of drugs used in Canada for the acute treatment of migraine in adults. Primarily meta-analyses and systematic reviews were included. Where these were not available for a drug or were out of date, individual clinical trial reports were utilized. Only double-blind randomized clinical trials with placebo or active drug controls were included in the analysis. Recommendations and levels of evidence were graded according to the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, using a consensus group.
Eighteen acute migraine medications and two adjunctive medications were evaluated. Twelve acute medications received a strong recommendation with supporting high quality evidence for use in acute migraine therapy (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ASA, ibuprofen, naproxen sodium, diclofenac potassium, and acetaminophen). Four acute medications received a weak recommendation for use with low or moderate quality evidence (dihydroergotamine, ergotamine, codeine-containing combination analgesics, and tramadol-containing combination analgesics). Three of these medications were NOT recommended for routine use (ergotamine, and codeine- and tramadol-containing medications), and strong recommendations were made to avoid use of butorphanol and butalbital-containing medications. Both metoclopramide and domperidone received a strong recommendation for use with acute migraine attack medications where necessary.
Our targeted review formulated recommendations for the available acute medications for migraine treatment according to the GRADE method. This should be helpful for practitioners who prescribe medications for acute migraine treatment.
The primary objective of this guideline is to assist the practitioner in choosing an appropriate acute medication for an individual with migraine, based on current evidence in the medical literature and expert consensus. It is focused on patients with episodic migraine (headache on < 14 days a month).
A detailed search strategy was used to find relevant meta-analyses, systematic reviews and randomized double-blind controlled trials. Recommendations were graded with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, using a consensus group. In addition, a general literature review and expert consensus were used for aspects of acute therapy for which randomized controlled trials are not available.
Twelve acute medications received a strong recommendation for use in acute migraine therapy (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ASA, ibuprofen, naproxen sodium, diclofenac potassium, and acetaminophen). Four received a weak recommendation for use (dihydroergotamine, ergotamine, codeine-containing combination analgesics, and tramadol-containing combination analgesics). Three of these were NOT recommended for routine use (ergotamine, and codeine- and tramadol-containing medications). Strong recommendations were made to avoid use of butorphanol and butalbital-containing medications. Metoclopramide and domperidone were strongly recommended for use where necessary. Our analysis also resulted in the formulation of eight general acute migraine treatment strategies. These were grouped into: 1) two mild-moderate attack strategies, 2) two moderate-severe attack or NSAID failure strategies, 3) three refractory migraine strategies, and 4) a vasoconstrictor unresponsive-contraindicated strategy. Additional strategies were developed for menstrual migraine, migraine during pregnancy, and migraine during lactation.
This guideline provides evidence-based advice on acute pharmacological migraine therapy, and should be helpful to both health professionals and patients. The available medications have been organized into a series of strategies based on patient clinical features. These strategies may help practitioners make appropriate acute medication choices for patients with migraine.
In our targeted review (Section 2), 12 acute medications received a strong recommendation for use in acute migraine therapy while four received a weak recommendation for use. Strong recommendations were made to avoid use of two other medications, except for exceptional circumstances. Two anti-emetics received strong recommendations for use as needed.
To organize the available acute migraine medications into acute migraine treatment strategies in order to assist the practitioner in choosing a specific medication(s) for an individual patient.
Acute migraine treatment strategies were developed based on the targeted literature review used for the development of this guideline (Section 2), and a general literature review. Expert consensus groups were used to refine and validate these strategies.
Based on evidence for drug efficacy, drug side effects, migraine severity, and coexistent medical disorders, our analysis resulted in the formulation of eight general acute migraine treatment strategies. These could be grouped into four categories: 1) two mild-moderate attack strategies, 2) two moderate-severe attack or NSAID failure strategies, 3) three refractory migraine strategies, and 4) a vasoconstrictor unresponsive-contraindicated strategy. In addition, strategies were developed for menstrual migraine, migraine during pregnancy, and migraine during lactation. The eight general treatment strategies were coordinated with a “combined acute medication approach” to therapy which used features of both the “stratified” and the “step care across attacks” approaches to acute migraine management.
The available medications for acute migraine treatment can be organized into a series of strategies based on patient clinical features. These strategies may help practitioners make appropriate acute medication choices for patients with migraine.
Patients with chronic migraine and medication overuse are significant consumers of health care resources.
To determine whether botulinum toxin type A prophylaxis reduces the cost of acute migraine medications in patients with chronic migraine and triptan overuse.
In this multicenter, open-label study, patients with chronic migraine (≥15 headache days/month) who were triptan overusers (triptan intake ≥10 days/month for ≥3 months) received botulinum toxin type A (95-130 U) at baseline and month three. Headache (HA) frequency and medication use were assessed with patient diaries, and headache-related disability by means of the MIDAS and Headache Impact Test-6 questionnaires.
Of 53 patients enrolled (mean age ± standard deviation, 46.5 years ± 8.4; 47 [88.7%] females), 48 (90.6%) completed the study at month six. Based on headache diaries, significant (P≤0.0002) decreases from baseline were observed for days per month with headache/migraine, days with any acute headache medication use, days with triptan use, and triptan doses taken per month. A significant (P<0.0001) increase from baseline in headache-free days per month was also observed. Prescription medication costs for acute headache medications decreased significantly, including significant reductions in triptan costs (mean reduction of -C$106.32 ± 122.87/month during botulinum toxin type A prophylaxis; P<0.0001). At baseline, 78% of patients had severe disability (MIDAS score) and 86.8% had severe impact due to headache (HIT-6 scores); at month six, this decreased to 60% and 68%, respectively.
Botulinum toxin type A prophylactic therapy markedly decreased costs related to acute headache medication use in patients with chronic migraine and triptan overuse.
Headache is the most common presenting symptom in neurology and constitutes more than one-third of primary care consultations. Organized according to the presenting features of the headache (acute, episodic and chronic), this handbook provides diagnostic and treatment information for both common and uncommon causes of headache. Making maximum use of lists, bullet points, summary boxes and illustrations, it allows the reader fast access to essential information where it is needed most. Each topic is dealt with succinctly, using up-to-date knowledge and experience of the authors, all of whom are headache experts from leading clinical centers in the USA and Canada. Providing comprehensive and detailed coverage to satisfy the needs of the busy neurologist, residents in neurology, neurosurgery, psychiatry and other fields of internal medicine, this book will also be a valuable guide to practising clinicians who do not deal with headache on a regular basis.