Elsevier

The Lancet Neurology

Volume 9, Issue 3, March 2010, Pages 285-298
The Lancet Neurology

Review
Current practice and future directions in the prevention and acute management of migraine

https://doi.org/10.1016/S1474-4422(10)70005-3Get rights and content

Summary

Migraine is a common and disabling brain disorder with a strong inherited component. Because patients with migraine have severe and disabling attacks usually of headache with other symptoms of sensory disturbance (eg, light and sound sensitivity), medical treatment is often required. Patients can be managed by use of acute attack therapies (eg, simple analgesics or non-steroidal anti-inflammatory drugs) or specific agents with vasoconstrictor properties (ie, triptans or ergot derivatives). Future non-vasoconstrictor approaches include calcitonin gene-related peptide receptor antagonists. Preventive therapy is probably indicated in about a third of patients with migraine, and a broad range of pharmaceutical and non-pharmaceutical options exist. Medication overuse is an important concern in migraine therapeutics and needs to be identified and managed. In most patients, migraine can be improved with careful attention to the details of therapy, and in those for whom it cannot, neuromodulation approaches, such as occipital nerve stimulation, are currently being actively studied and offer much promise.

Introduction

Migraine is a complex, common, and disabling disorder of the brain, whose mechanisms are only now being unravelled.1, 2, 3 It is characterised by sensory symptoms: pain and sensitivity to normal afferent information, such as light, sound, and head movement. The attack manifestations are defined by the International Headache Society,4 although the diagnostic criteria do not include common considerations such as the familial nature of the disorder.5 Migraine is one of the primary headache disorders in which headache is part of the clinical phenotype of the syndrome, in contrast to secondary headaches in which head pain is a consequence and a symptom of another disorder. Episodic migraine, by definition, occurs on fewer than 15 days per month and chronic migraine occurs on 15 days or more per month.6

In terms of acute treatment, migraine can be managed with available substance groups such as analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), ergotamine derivatives, and triptans, with their different modes of administration. New strategies in acute treatment are very promising and the calcitonin gene-related peptide (CGRP) receptor antagonists and serotonin 5-HT1F agonists are in the late stages of development. Preventive treatment can be divided into pharmacological and non-pharmacological therapies; one approach certainly does not exclude the use of the other, and a combination of pharmacological and non-pharmacological approaches, such as patient education, acupuncture, biofeedback, and exercise, can be useful in clinical practice. Medication-overuse headache (MOH),7 which is caused by the regular use of analgesics or specific anti-migraine treatments that can increase headache frequency, is very much a problem in migraine management.8

In this Review, the subject of migraine treatment alone is covered. A more detailed coverage of the pathophysiology and diagnosis of headache disorders can be found elsewhere.3, 9, 10, 11, 12, 13 Available and awaited future approaches to migraine treatment will be outlined and, where possible, the evidence base is cited, although many care strategies remain to be rigorously tested. We discuss both acute and preventive treatment, as well as strategies for the management of medication overuse.

Section snippets

General treatment principles

Once the diagnosis has been confirmed, one usually starts the management process by explaining the condition to provide an understanding of the problem and to set realistic expectations. This is helpful for patients because it engages them in their own care, which in turn facilitates management. A headache diary will often be very instructive in the planning and evaluation of therapy. Recording affected days, pain severity, and medication use and response, as well as obvious triggers (eg, days

Acute attack treatment

Current attack treatments fall into two categories: disease non-specific—analgesics and NSAIDS; and more disease specific—ergot-related compounds and triptans. Of note, specificity is relative, because triptans, for example, are also effective in the acute treatment of cluster headache,16 and perhaps other types of primary or even secondary headache.17, 18 To avoid medication overuse, patients need to be counselled on the frequency of use of acute attack medicines,19 and even simple analgesics

Preventive treatment

Preventive therapy is a crucial component of the management strategy to reduce migraine disability, and is indicated in about a third of patients with migraine.107 Unfortunately, the mechanisms of action of current preventive treatments are not well understood. One potential mechanism could be the suppression of CSD,80 as most preventive medicines seem to inhibit CSD.108 Silent CSD might occur during migraine without aura,109 and its suppression would explain the effectiveness of migraine

Alternative management strategies

Migraine is clearly an inherited disposition to headache that is triggered by change: too much or too little sleep, skipping meals, weather change, change in exertion patterns, or change in stress. Thus a balanced, regular lifestyle seems desirable, although it has not been proven by evidence-based medicine that education of patients and other adjustments to lifestyle truly reduce the frequency or severity of headaches. The same applies to the careful intake of recognised aggravating

Management of medication overuse

Medication overuse is effectively defined as the consumption of triptans, ergotamines, opioids, or combination analgesics on 10 days or more per month, with the International Headache Society allowing 15 days per month for simple analgesics.7 It seems essential that analgesic overuse should be reduced and eliminated to determine the underlying headache phenotype and to start managing the problem effectively.215 There is no universally accepted, evidence-based approach to the management of MOH.

Conclusions

Effective migraine management is possible in most patients. However, much work remains to be done to improve the evidence base of the current approaches, particularly in the management of chronic migraine, and to elucidate their mechanisms of action. Medical therapy is still the mainstay of migraine treatment, but migraine is a complex disorder for which comorbidities and patient preferences have to be taken into account. Non-pharmacological treatments can certainly help to reduce the disease

Search strategy and selection criteria

We searched PubMed with the keywords “migraine”, “treatment”, “randomized controlled”, and “trial”. All papers published from 1966 to November, 2009, in English or German, were considered if they described a controlled trial. Abstracts located by this search were reviewed and, if appropriate, the full articles obtained. References cited within selected articles were also considered. In addition, review books, abstracts, and articles that had previously come to the attention of the authors

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