Primary care doctor: What are the common migraine triggers?
Headache specialist: Certain foods (Table), alcohol(Drug information on alcohol), stress, and menstruation are among the most common triggers.1,2 A comprehensive treatment plan should include the identification of triggers to prevent attacks.
This patient reported overuse of caffeine(Drug information on caffeine), lack of sleep, and stress—all of which could trigger her migraines. Lifestyle changes and medication were therefore necessary to control her migraines. Although it is important to identify migraine triggers in individual patients, a long list of items to avoid can be burdensome. Therefore, I generally counsel my migraine patients to eliminate caffeine, chocolate, monosodium glutamate, artificial sweeteners, and alcohol; to maintain regular sleeping and eating habits; and to exercise regularly.
Primary care doctor: How can comorbid conditions affect migraine?
Headache specialist: Affective disorders, such as depression, are common in migraineurs. Both clinic-based and epidemiologic studies support an association between migraine and major depression. Epidemiologic studies also support an increased prevalence of bipolar disorder, panic disorder, and some anxiety disorders in migraineurs. Other comorbid conditions frequently found in migraineurs include epilepsy, stroke, rheumatologic disorders, and essential tremor.3 Some comorbid conditions may limit treatment options. Other comorbidities may provide unique therapeutic situations in that some drug classes may be effective for both conditions. For example, certain antiepileptic agents can prevent both migraine and seizures.
In this patient’s case, antidepressant therapy may have helped relieve her depressive symptoms as well as her migraines.4 Antidepressants offered an appropriate substitute for her original analgesics, which were ultimately discontinued.
In short: for a migraineur with a comorbid condition, maximal therapeutic effect depends on treatment of the comorbidity.
Primary care doctor: What are the goals of therapy for acute migraine?
Headache specialist: There are several facets5:
- Treat attacks rapidly and consistently.
- Prevent headache recurrence.
- Restore the patient’s ability to function.
- Minimize use of backup medication.
- Promote the patient’s involvement in care, and optimize the tolerability of treatment.
Primary care doctor: How is migraine management stratified to achieve these goals?
Headache specialist: Therapy is stratified according to the degree of pain intensity and associated disability. This patient had recurrent moderate to severe migraines that adversely affected her ability to function. The severity of symptoms and her high level of disability indicated the need for acute migraine-specific therapy. A triptan was the logical choice. These agents have been shown to reduce or eliminate headache pain, prevent headache recurrence, and improve functioning.6
Primary care doctor: Why was this patient advised to medicate at the first sign of headache?Headache specialist: Our understanding of migraine pathophysiology supports early intervention. Migraine is progressive: it begins with the sensitization of the intracranial blood vessels and meninges. In susceptible patients, these impulses of pain—if uncontrolled or untreated—act on the trigeminal nucleus caudalis, which further activates the peripheral system. If these impulses are allowed to progress to the second- and third-order neurons, then cutaneous allodynia and central sensitization exacerbate the inflammatory process.7,8 Activation of these second-order neurons in the thalamus and third-order neurons in the cortex results in hypersensitivity and throbbing pain. Early intervention when the pain is still mild (ie, during the first hour of a migraine attack before central sensitization occurs) may constitute a window of therapeutic opportunity for such medications as the triptans.
This patient had been waiting for her pain to become moderately intense before taking almotriptan(Drug information on almotriptan). This diminished the efficacy of the medication.
Primary care doctor: Are there any clinical trial data to support the early use of triptans?
Headache specialist: Yes. There are good and plentiful data demonstrating that all triptans—when used as an early intervention in migraine attacks—will abort headaches more quickly and result in a greater pain-free response than they will if headache treatment is delayed.6,9-12 Several studies indicate that early intervention:
- Interrupts progression from intracranial vessel sensitization to central sensitization.
- Results in an increased 2-hour pain-free rate.
- Reduces the need for rescue medication.
- Reduces the rate of headache recurrence.
- Increases patient relief.
Because of these findings, the use of triptans during the mild phase of migraine attack is gaining support.9,12-14OUTCOME OF THIS CASE
At 1 month, the patient had stopped using caffeine-containing medications and had eliminated caffeine from her diet. Both the frequency and severity of her headaches had decreased, and her sleep patterns had improved. To combat depression, the dosage of sertraline(Drug information on sertraline) was increased to 100 mg/d.
At 2 months, headache frequency was significantly reduced, but the patient continued to experience 2 to 5 episodes per month. Most of these resolved with a single dose of almotriptan, although an additional dose was occasionally necessary. The patient's depressive symptoms diminished, and she had more energy and a greater ability to cope with activities of daily living.
At 3 months, headache frequency had dropped to 1 to 3 times per month and symptoms resolved with a single dose of almotriptan. The patient reported that she was no longer missing work and was able to enjoy her home life again.