Intercepting migraine: Results of early therapy with nonspecific and migraine-specific agents

Abstract

Migraine is a pervasive neurologic disorder characterized by recurrent attacks of disabling headache. Despite significant morbidity with impact that may be physical, emotional, social, and economic, treatment of these attacks is often delayed. Patients frequently delay therapy until the more severe or "textbook" symptoms arise, often mistaking the earliest stages as representative of "tension" or "sinus" headaches. Clinicians may recommend deferral of treatment until the more severe levels of pain are seen, perhaps in a misguided attempt to conserve pharmaceutical resources. Patients and clinicians seem more comfortable with perspectives of "being sure it's a migraine" and "not wasting the medication on milder headaches." Therefore, patients and clinicians must learn the latest lessons in migraine: 1) mild migraine usually progresses to more severe levels if left untreated, 2) early treatment is more effective than delayed treatment, 3) early treatment may result in lower rates of adverse events and headache recurrence, and 4) early treatment is cost effective. As clinicians advocate the early treatment of migraine in its mild phase, evidence to support this recommendation has finally become available. I educate my migraineurs to consider each typical headache to be a version of migraine. Most patients with migraine will experience "little" headaches that they often mislabel as tension, sinus, regular, stress, or normal headaches. Instead of these terms, I have them consider their attacks as "small migraines" and "big migraines," with the smaller headaches often evolving into the bigger episodes. Given such a foundation, I advise them to treat at the beginning of the headache, perhaps earlier than they would have previously identified it as a migraine. They must capture the attack while it "whispers migraine" instead of delaying until the attack "shouts migraine." Early treatment of migraine is successful for most patients. However, there are situations in which treatment of the mild phase is not advisable or possible. In patients with frequent or daily migraine, treatment must be reserved for the most disabling attacks. We must advise treatment as soon as the migraine becomes moderate to severe. Certain patients, or certain headaches in some patients, may not progress through a mild phase, perhaps because of rapid escalation or because migraine is already severe upon awakening. Here we encourage migraineurs to treat as soon as possible, often with parenteral formulations of medication. The reaction of the patient (speed of dosing) and the action of the medication (speed of onset of the drug) will ultimately play roles in the successful interception of each attack.

Examining the Interrelationship of Migraine Onset, Duration, and Time to Treatment

“…Reasons for delaying treatment varied and were similar to other reasons found in the literature 7,29‐31 . Two important reasons in this working population included not having the migraine medication readily available and, anecdotally from the verbatim comments, waiting a migraine out to see if it was a true migraine and not just a sinus or tension headache.…”

“…Two important reasons in this working population included not having the migraine medication readily available and, anecdotally from the verbatim comments, waiting a migraine out to see if it was a true migraine and not just a sinus or tension headache. Initial mischaracterization of migraines as less‐severe headaches is common and has been documented by Kaniecki et al 31 . Educating patients on how to accurately identify migraines may assist patients in treating the condition earlier and thereby alleviate the burden in a shorter timeframe 32 …”

“…Published studies on the chronobiology of migraine have demonstrated a lack of consensus on when migraines most often occur or if a pattern to migraine attacks can even be established. However, a rhythmic pattern has been found in several studies 1‐44 . In addition, migraine attacks appear to occur most frequently in the early morning (morning migraines) (eg, 6 am to 12 pm ) or upon wakening (waking migraines), which can occur at any time of day or 1,2,4 night 1,2,4 depending on a subject's sleep/wake patterns.…”