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Migraines are now viewed as a chronic disorder with episodic manifestations, and emphasis should be put on evaluating impairment between headache attacks. This is the gist of a new consensus statement recently released by the National Headache Foundation (NHF), an organization focusing on migraine prevention.
"In the past, migraine was considered an episodic disorder and treated with acute abortive medications such as the triptans. However, in recent years, new scientific data and epidemiological research have led to a new paradigm shift in migraine treatment," said Jackie Kwong, Pharm.D., Ph.D., assistant professor at the University of Georgia College of Pharmacy.
Imaging studies have suggested that migraine may lead to progressive brain changes, and an epidemiology study has found that some patients suffering from episodic migraine may progress to chronic daily headache, Kwong explained. "Therefore, there is an interest in shifting the focus from aborting migraine attacks after they've occurred to preventing them from happening at all."
The American Migraine Communications Study (AMCS) found that only 10% of patient visits to their physician involved discussion of migraine impairment. This study concluded that clinicians need to ask patients "open-ended" questions.
Specifically, the NHF Migraine Prevention Summit Consensus Statement states that acute medication is not always adequate to control migraine attacks. In an effort to minimize the frequency and intensity of migraine, NHF recommends initiating preventive therapy if headaches occur two or more times per month with disability on three or more days per month that significantly interferes with daily routines. Preventive treatment should also be instituted if the patient is using acute medication more than twice per week, or if acute therapies are contraindicated, not tolerated, or are ineffective. Clinicians should also assess a patient's impairment during the interictal period-the time between migraine attacks.
"According to the statement, migraine preventive medication should be considered in patients experiencing frequent disability between migraine attacks, and individualized migraine treatment should be encouraged," Kwong said. "It doesn't recommend a specific medication but does mention that beta-blockers and antiepileptic drugs are approved by the Food & Drug Administration for migraine prevention." Kwong added that other medications, such as calcium-channel blockers and antidepressants, are also used off-label for migraine prevention but are not mentioned in the new guide. The statement also advises clinicians to give particular attention to choosing medications that are unlikely to interfere with concomitant treatments and comorbid conditions. "Individualizing therapy is the key to optimizing treatment, because each patient's response and tolerability to medication are different," added Kwong.
The consensus also advises that patients need realistic expectations about treatment outcome, specifically time to response. Preventive therapies may take six weeks or longer to reach full clinical effect. Kwong agrees. "Patient nonadherence can be a problem when patients do not see any immediate effect on their migraine frequency or severity but are experiencing side effects," she explained. She believes that pharmacists can play an active role by providing patient counseling and discussing what patients should expect in terms of side effects and treatment effect to encourage adherence to therapy. Also, she said, because many migraine preventive medications have multiple indications, pharmacists should actively talk to patients and understand their medical history to ensure that relevant information is provided.
The NHF Migraine Prevention Summit Consensus Statement can be found on-line at http:// http://www.headaches.org/nhfnewsletter1.pdf/.