Early Treatment in Migraine: How Strong is the Current Evidence?

Abstract

Over the last 10 years, triptans (serotonin 5-HT(1B/1D) receptor agonists) have proved to be efficacious in treating migraine pain. However, recent evidence suggests that patients are still not receiving optimal pain management, particularly in clinical trials, where triptan treatment is generally not initiated until pain has reached moderate intensity. Pathophysiological evidence indicates that if treatment is initiated at an early stage, while pain is still mild and before the onset of central sensitization, outcomes for patients may be improved. In addition, a small number of clinical trials have been reported in which triptans were taken early (within 1 h of pain onset) or while pain was still mild; although constraints of trial design and data analysis limit definite conclusions, overall the results suggest that this early/mild approach results in more rapid and sustained pain relief. New studies are therefore needed to clarify the clinical benefits of early treatment, whilst taking into account potential risks, such as medication overuse. Ultimately, migraine treatment strategies require optimization in order to meet patient expectations and to reduce the current burden of migraine-associated disability.

Efficacy of early vs. late use of frovatriptan combined with dexketoprofen vs. frovatriptan alone in the acute treatment of migraine attacks with or without aura

“…We may hypothesize that using a combination of a drug with a fast action (dexketoprofen) and of a drug with a slow onset, but a prolonged effect (frovatriptan), may overcome the need to treat all attacks at the earliest opportunity. Indeed, there is controversy as to whether migraine patients should be advised to treat all attacks early with triptans [2, 19–23]. Rather, some authors suggest that patients should be free to take their medication as soon as they are sure they are developing a migraine headache, because this could reduce the risk of medication-overuse headaches and related adverse drug reactions [2, 20, 23].…”

Early (≤1-h) vs. late (>1-h) administration of frovatriptan plus dexketoprofen combination vs. frovatriptan monotherapy in the acute treatment of migraine attacks with or without aura: a post hoc analysis of a double-blind, randomized, parallel group study

“…Here, even the early intake resulted significantly more efficient than monotherapy at promoting pain-free activity at 2 and 4-h. FroDex intake after 30-min but within 1-h from headache onset may have major and longer benefits than triptan monotherapy on pain control, even with lower NSAID dosing. Current evidence suggests the administration of triptan monotherapy as early as possible from headache onset to ensure the best effect [3,18,19], but the early use of triptan for all migraine attacks is still controversial [16,20,21]. This study showed that the addition of dexketoprofen seems to contribute to high pain- .…”

“…Thus, the combination of triptan plus NSAIDs could reduce the risk of medication-overuse headaches and related adverse drug effects [11,16]. In this regard, a two-drug combination, as that between frovatriptan and dexketoprofen, ensuring both quick and sustained pain-free activity, should be regarded as a useful treatment option for migraineurs [22,23].…”

“…Since, early treatment was never univocally defined in the various studies of triptans' efficacy, with most common time points set at 30 or 60 min of pain onset [13][14][15][16] and since the post hoc analysis on early intake of frovatriptan plus dexketoprofen at 30 min was already published, we decided to further investigate whether frovatriptan plus dexketoprofen or frovatriptan alone could have shown different efficacy when taken within or after 1-h from headache onset.…”

Cost-Effectiveness Analysis of Early versus Non-Early Intervention in Acute Migraine Based on Evidence from the ‘Act when Mild’ Study

“…[31] Furthermore, patients might not always be able to distinguish migraine from tension-type headache at onset of the attack. [32,33] Therefore, following an early treatment strategy, a few patients might treat some (neither a priori nor a posteriori identifiable) headaches with a triptan that, if they had waited, would have been left untreated or would have been treated with another drug (e.g., when identified as tension type headache, with a NSAID). Given that triptans are very tolerable drugs, [11,12] this is not a major concern from a clinical perspective, but from the economic point of view it implies a certain increase in drug consumption.…”