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Migraine Therapy Selection Not an Isolated Decision

Kate Traynor

Pharmacists involved in the treatment and prevention of migraine often find themselves weighing the complexities of each patient’s symptoms before choosing from an assortment of treatment options.

Julie A. Dopheide, associate professor of clinical pharmacy and psychiatry at the University of Southern California Schools of Pharmacy and Medicine in Los Angeles, said that, in her experience with psychiatric inpatients, those seeking relief from migraines also have other medical issues that must be considered. Her patients are typically admitted for reasons other than migraine, which is then treated along with the psychiatric symptoms.

“When you get into the history of people with migraines,” Dopheide said of her inpatients, “you tend to find a lot of comorbidity, whether it’s an anxiety disorder or a mood disorder ... or they can have any number of other conditions.”

Deborah A. King, assistant professor of pharmacy practice and medicine at the University of Mississippi Medical Center in Jackson, works in a clinic with patients who are undergoing treatment for hypertension.

King said that many of these patients also have migraines but mistake them for hypertension-related headaches. “The headaches have nothing to do with their blood pressure,” she said. “Their headaches are more atypical migraines.”

Conversely, patients who specifically seek treatment for migraine may not be aware that they have other medical conditions that should be addressed, said Sara L. Noble, who does clinical work with the University of Mississippi’s neurology department and also serves as a clinical education consultant for Pfizer Inc.

Noble said that a migraine evaluation can uncover conditions, such as hypertension and dyslipidemia, that might have gone unnoticed by the patient.

“The pain is what triggered them to come for the visit,” Noble said. She added that the neurology department holds a weekly afternoon migraine clinic that typically generates 20–30 patient visits.

Guidelines. Once the migraine is diagnosed, clinicians have a variety of treatment options from which to choose.

A concise treatment guideline (PDF) aimed at primary care physicians was issued in late 2002 by the American Academy of Family Physicians and the American College of Physicians–American Society of Internal Medicine (AAFP/ACP-ASIM).1 Included in the guideline is a table showing specific AAFP/ACP-ASIM recommendations alongside those by the U.S. Headache Consortium, issued in 2000.

King described the AAFP/ACP-ASIM guideline as “a good summary” of the available information on migraine treatment, but she and Noble said they tend to favor the Headache Consortium’s recommendations (PDF).

“For some of the reasons, like acute therapy, the U.S. Headache Consortium recommends migraine-specific agents initially, and the AAFP is not quite that strong,” King said. Her preference is for migraine-specific agents that provide pain relief, limit migraine recurrence, and are useful for long-term therapy.

The Headache Consortium named serotonin type 1-receptor agonists, known colloquially as triptans, and dihydroergotamine as the preferred first-line migraine-specific agents for the treatment of acute migraine episodes.

Said Noble: “Triptans certainly would be utilized appropriately as a first-line agent, depending on the severity of the headache.”

In contrast, the AAFP/ACP-ASIM guideline recommends nonsteroidal antiinflammatory drugs (NSAIDs) as first-line therapy for most acute migraine episodes, reserving the selective serotonin agonists and dihydroergotamine for patients whose headaches have not responded to NSAIDs.

Dopheide, who said she keeps abreast of the migraine literature and drug-approval information rather than rely on a single clinical guideline, sees a place for NSAIDs as first-line therapy during acute migraine episodes.

“If there’s no contraindication to an NSAID, then I think that would be a first-line treatment because they’re effective and they work quickly,” she said. NSAIDs are economical, she noted, and do not normally increase patients’ risk of cardiovascular problems.

The labeling for the various selective serotonin agonists warns about the potential of these compounds to cause coronary artery vasospasm, which can lead to serious cardiac events, including death.

“If NSAIDs are ineffective or can’t be used,” Dopheide said, “I’d go with the triptans.” She noted that her patients seem to prefer the orally disintegrating tablets, such as Merck’s rizatriptan (Maxalt-MLT) and AstraZeneca’s zolmitriptan (Zomig-ZMT), which dissolve on the tongue and do not require the patient to drink a liquid.

From the patient’s point of view, Dopheide said, “there’s just something pleasant about knowing that [the tablet is] dissolving right away.... You get the impression that it’s really going to work fast.” Such formulations, she said, may be the preferred option for patients whose migraine symptoms include nausea.

For migraine prevention, the Headache Consortium (PDF) recommends as first-line therapy four drugs that are available in the United States: amitriptyline, divalproex sodium, propanolol, and timolol. AAFP/ACP-ASIM’s guideline includes a fifth agent, sodium valproate. Because these drugs have indications for conditions other than migraine, clinicians have the opportunity to treat more than one ailment with a single product.

“We look at the severity of the headache, plus the comorbid disease state,” King said about preventive therapy.

For patients who have migraines in addition to hypertension, King said that the clinic’s staff tends to prefer medications that are well accepted for both their antihypertensive and migraine-prophylaxis effects. Propanolol and timolol would be the first choices in this situation, according to AAFP/ACP-ASIM and Headache Consortium recommendations.

New consideration. A recently published article describing the use of an angiotensin II-receptor blocker (ARB) for migraine prevention has captured King’s attention.2

According to the report, candesartan worked well at preventing migraines and had a safety profile similar to that of the placebo used in the study. The report’s authors speculated that the drug’s migraine-prevention properties may be related to its ability to reduce angiotensin II-related vasoconstriction and catecholamine release.

“It makes perfect sense that [ARBs] would work,” King said. “That’s something I’ve been interested in looking at for a while.”

Pharmacists’ role. Noble and King emphasized that pharmacists can play an important role in the prevention and treatment of migraine.

Noble said that pharmacists can teach patients whose migraine therapy requires intranasal sprays or subcutaneous injections how to use the delivery devices.

Said King: “I think pharmacists are best able to identify when there are comorbid conditions . . . and what drug should be used to maybe treat both conditions.” Likewise, she added, pharmacists can determine which drugs should not be used in specific patients to avoid aggravating comorbid conditions.

During interactions with patients, King said, there is “a tremendous opportunity” for pharmacists to recognize and identify migraine-related issues, such as headache recurrence, tolerability to therapy, and adherence to therapy. In that role, she said, “pharmacists are kind of the gatekeepers for health care.”

  1. Snow V, Weiss K, Wall EM et al. Pharmacologic management of acute attacks of migraine and prevention of migraine headache. Ann Intern Med. 2002; 137:840-9. 
  2. Tronvik E, Stovner LJ, Helde G et al. Prophylactic treatment of migraine with an angiotensin II receptor blocker: a randomized controlled trial. JAMA. 2003; 289:65-9.