Strategies for Treating Migraine

Peter L. Salgo, MD: Let’s talk about current strategies for migraine treatment, on the table, that doctors know about right now. Let’s talk about acute treatment. What is out there? What is the strategy for dealing with acute headaches?

Peter Goadsby, MD, PhD: Most doctors know about simple analgesics. Patients, of course, will get their aspirin or acetaminophen or naproxen or ibuprofen from the local pharmacy, or wherever they get it from. When patients see a doctor, the first thing that must be noted for acute therapy is to make sure that the dose is adequate. Very typically, people will take half a dose of ibuprofen. They may as well not take it. So, doctors ought to know that they should adequately dose acute therapies. And then, there are specific migraine therapies that have been around for about 20 years, the so-called triptans, or serotonin 5-HT_1B or F-HT_1D receptor agonists. Sumatriptan is the archetypical one. There are half a dozen available. They really did revolutionize, to some extent, the acute treatment of migraine.

Peter L. Salgo, MD: OK, that’s acute. What about preventing migraine? Where do we go with that?

Malaika Stoll, MD, MPA: There are some common medications out there that have demonstrated efficacy. We know about the beta blockers and the antidepressants, for example, that I think some patients really do benefit from.

Peter Goadsby, MD, PhD: Interestingly enough, from a mechanistic perspective and because I think it’s important, not all beta-blockers work. We don’t understand that. Not all antidepressants work. There’s evidence for some of the beta-blockers, like propranolol. There’s evidence for some antidepressants, like amitriptyline, but the studies with fluoxetine, for example, were negative. There’s evidence for some of the blood pressure drugs, like candesartan, but the telmisartan study was negative. It’s interesting. We use the terms blood pressure drugs and so forth, but there are some paths of those mechanisms that are clearly important and some that are not.

Malaika Stoll, MD, MPA: Which is so interesting. In other disease categories, you can go across the board with…

Peter L. Salgo, MD: That just reminded me of NSAIDs [nonsteroidal anti-inflammatory drugs] for heart disease. In other words, if you’re going to give aspirin for prophylaxis for atherosclerotic disease, it works. The other NSAIDs, not. Some NSAIDs increase your risk for heart disease. As my grandmother would say, “Go figure.” There’s got to be some evidence here.

Let’s go over the triptans. What’s the optimal timing? Is there a limit? What’s the duration of therapy? Are there any contraindications?

Jill Dehlin, RN: Well, the issue with triptans, from the patient’s perspective, is that patients are only given a limited number of triptans per month. If you have chronic migraine, it’s difficult to know which migraine is triptan-worthy.

Malaika Stoll, MD, MPA: So, you have to ration.

Jill Dehlin, RN: Yes.

Peter L. Salgo, MD: If you’re going to use it, is there a best time to give it?

Jill Dehlin, RN: Yes, the earlier the better.

Peter L. Salgo, MD: So, if you have aura, give it? If you’re getting pain and you think this is a migraine, give it?

Jill Dehlin, RN: Yes. But if you wait to see if it’s really a migraine, it’s too late.

Peter L. Salgo, MD: Then it’s too late. But then somebody is going to deny you, if you’ve used up your N, where N is an integer, which is probably smaller than you’d like. If you use up all of your doses, you’re not going to have it for your next migraine.

Jill Dehlin, RN: Right.

Peter L. Salgo, MD: So you could understand why people would delay.

Jill Dehlin, RN: Yes, I do. Absolutely. That’s an issue. But it’s also a problem if you use too many triptans. Then you may be susceptible to medication overuse or rebound headaches.

Peter L. Salgo, MD: What about cardiovascular disease? Is there an impact? Is there a problem with using the triptans in patients with ischemic heart disease?

Jill Dehlin, RN: Yes.

Peter L. Salgo, MD: Why?

Jill Dehlin, RN: Personally, I’ve tried triptans and it really affected my blood pressure in a very negative way. It’s contraindicated for people who have ischemic heart disease. You can add to that, Dr Goadsby.

Peter Goadsby, MD, PhD: The advice for using triptans early is to use when the pain is established. There are 3 randomized controlled trials. There are placebo-controlled studies. Treating during aura is not a good idea. The important advice is to treat early in the pain phase.

Peter L. Salgo, MD: OK. Use it for the pain, not the aura. It’s like gravity. It’s not just a good idea, it’s the law.

Malaika Stoll, MD, MPA: Right.

Peter L. Salgo, MD: Let’s go way back into medical history now. Ergots, or dihydroergotamine, this was old when my professors were young and yet it’s still out there in the formulary. Does it work?

Jill Dehlin, RN: Yes, it does work for some people.

Malaika Stoll, MD, MPA: For some.

Peter L. Salgo, MD: There’s a quizzical tone to your voice. Why?

Jill Dehlin, RN: Because there are other options that may be safer and more efficacious than ergots.

Malaika Stoll, MD, MPA: I think it’s the population base versus the individual. If you look at the studies, you’ll find that the triptans are better. But the individual in front of you may have benefit.

Peter L. Salgo, MD: But the ergots are really well established. They’re older therapies. They have been wrung out. They are not for everybody. I bet they’re cheap?

Malaika Stoll, MD, MPA: We cover them.

Peter L. Salgo, MD: Let’s talk about medication overuse.

Peter Goadsby, MD, PhD: Dihydroergotamine has been around since 1945. There are 2 problems with it. First, it induces nausea so often that you have to take some antinauseant with it and accept that there might be side effects of the other treatment that you’re taking. It’s a really unfortunate thing, in medicine, when you have to give adjunctive drugs for the side effect of the drug that you’re about to give. It’s certainly not ideal.

The second thing is that the absorption rates aren’t great. They really work best when you inject them. Not many people want to break the thing open, draw it up, and inject themselves when they’re having a dreadful migraine.

Malaika Stoll, MD, MPA: That’s not recommended.

Peter L. Salgo, MD: It’s not recommended.

Peter Goadsby, MD, PhD: Not recommended, no.

Peter L. Salgo, MD: From a purely pragmatic point of view, if you’re getting nauseated and you’re having vomiting from the ergots, you’re going to vomit some of the ergots.