Predicting Who Will Respond to Acute Migraine Treatment
It has been over a decade since the American Migraine Prevalence and Prevention (AMPP) Study was completed and we’re still getting valuable information from the data collected. Recently a group of researchers took another look at AMPP data to identify what factors might play a role in the effectiveness of acute migraine treatments. The results were published in the December 2016 issue of Headache.
When testing new acute migraine medications, clinical trials use two markers to determine treatment effectiveness. First, they test to see if a given treatment can relieve pain within two hours of administration. Next, they determine if patients remain pain-free for a full 24 hours. Treatments that can do both are considered effective. Whether or not these treatment goals are met in the general population has never been studied until now.
A self-administered screening questionnaire was sent to 120,000 households as part of the original AMPP study. In the second phase of the study, 24,000 adults were selected who had reported at least one “severe headache” in the previous year. Over the next five years, each participant was asked to complete other questionnaires about sociodemographics, various headache features, comorbid health conditions, and other information. The 2006 questionnaire included The Migraine Treatment Optimization Questionnaire. Data from this questionnaire was used for this study. Individuals who responded to this questionnaire were included in this study if they met the ICHD-3 beta criteria for episodic migraine and reported use of acute medication to treat migraine attacks.
The objective of this study was to determine what factors may contribute to the success or failure of acute migraine treatment. Sadly, the majority of people living with migraine do not get reliably good results. More often than not, these acute treatments fail. Fifty-six percent of those surveyed said that their acute treatments failed to consistently provide relief within two hours. Over 53 percent also reported that over half the time their pain returned within 24 hours.
Types of treatment used
Only 18.3 percent reported using triptans for acute treatment of migraine. Even though the data is over 10 years old, I was surprised that so few people were using triptans. It’s not like these drugs are new to market. This study did not investigate reasons for low triptan use, so it is still not known if prior triptan failure or contraindications are responsible for these low numbers. Perhaps there are still millions of people living with migraine who have never used a triptan to abort a migraine attack.
The vast majority of people reported using NSAIDs and general analgesics instead. They also reported much lower treatment success rates than those who used triptans. Of those using triptans, less than 22 percent used them alone. Most used additional treatments, including NSAIDs, acetaminophen, aspirin, barbiturates, opioids, midrin equivalents, and ergotamines.
Several factors were associated with treatment failure at either two or 24 hours, or both. Patients reporting higher pain intensity, frequent headache days per month, allodynia, depression, or medication overuse were more likely to report acute treatment failure. Those with higher BMI, smokers, men, and those who were unmarried were also at risk for poor outcomes.
The good news is that some factors protect patients from poor results. Those using preventive treatments were more likely to have good response from acute medications. Women, those who were married, and those with health insurance also reported better acute treatment response.
Getting good results from acute treatment is an essential part of migraine management. Knowing that you can successfully and consistently abort an attack improves self-efficacy, encourages an internal locus of control, and lowers the likelihood of comorbid depression. Without effective abortive tools, many people feel like victims and lose hope all too easily.
This study helps doctors identify individuals who may be a greater risk for treatment failure. Most of these factors can be modified to reduce risk. By talking with patients about their risk factors, offering more aggressive treatment options (including behavioral therapy and neuromodulation), and teaching patients how to lower their risk, doctors can begin to offer a tailored approach to acute migraine treatment.
Treatment success builds confidence.
I know from experience that my self-confidence dramatically increased when I was finally prescribed a triptan. For the first time in 20 years, I had hope. It was the first success that led to many more. Years later, my doctor switched me to a longer-lasting triptan after we discovered that my pain consistently returned within 24 hours of each attack. The use of a different triptan cut my headache days almost in half. It was such a confidence booster to finally have the tools to stop a migraine attack in its tracks.
If you are not getting good results from your acute migraine treatments, don’t just accept that nothing else can be done. Talk to your doctor about your options. You might be surprised to learn just how many choices are available.
More helpful articles:
1 Lipton R, Munjal S, Buse D, et al. Predicting Inadequate Response to Acute Migraine Medication: Results from the American Migraine Prevalence and Prevention (AMPP) Study. Headache. 2016; 56(10):1635-1648. DOI:10.1111/head.12941.