Interesting parallels in poor treatment and treatments. Appears we are not the poor lost cousin in our pain.
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Migraine Management in US Gets Low Marks
Alice Goodman
May 09, 2013
New Orleans, Louisiana — Migraine is underdiagnosed and often inappropriately treated in the United States, despite the availability of accepted guidelines for diagnostic criteria and effective treatments. Migraine is an incurable but manageable condition, and drugs are effective if used appropriately, according to Richard Wenzel, PharmD, from the Diamond Headache Clinic and the Inpatient Unit of St. Joseph Hospital in Chicago, Illinois.

"Migraine affects 30 million sufferers in the US, but only half have been diagnosed and the other half are unaware of their illness," Wenzel stated. "Barriers to effective treatment include incorrect self-diagnosis and ineffective treatment, which are potentially resolvable via patient education."

In a presentation here at the American Pain Society (APS) 32nd Annual Scientific Meeting, Wenzel told the audience that clinicians need to incorporate one of several validated tools for diagnosing migraine, such as ID MIGRAINE, a simple and rapid 3-question test that can be given in less than 1 or 2 minutes.

Once the diagnosis is made, the MIDAS (Migraine Disability Assessment) or HITS (Headache Impact Test) can measure the degree of disability associated with migraine: These easy-to-use tools can also help determine the effectiveness of treatment over time, he said.

"We need to expand the use of these tools. Remember, MIDAS and HITS are not diagnostic," Wenzel said.

Disability Similar to Quadriplegia

The degree of disability associated with migraine is not trivial. In fact, a migraine episode is associated with as much disability as quadriplegia or cancer, he noted.

Ninety-eight percent of people take medications during a migraine attack, and 50% use exclusively over-the-counter (OTC) products, he continued.

Anywhere from 50% to 80% of patients with migraine develop chronic daily headache (also called transformed migraine). Risk factors for chronic daily headache include episodic migraine, caffeine overuse, obesity, and stressful life events. Medication overuse is a factor in 80% of transformed migraine.

Narcotics are commonly prescribed for migraine, yet there is no evidence that these drugs are effective, he continued. Patients with chronic daily headache who take narcotics should be weaned off of them.

"I am on my own campaign to rid the world of Fiorinal and Fioricet [butalbital/acetaminophen/caffeine]. These drugs cause a 2-fold increase in the incidence of migraine and are the worst drugs to prescribe to a migraine sufferer," he told listeners. "Narcotics are never a treatment choice for episodic migraine, but 1 out of 3 patients with episodic migraine are prescribed narcotics."

Migraine drugs fall into 2 major classes: abortive drugs, with the goal of return to function, and preventive drugs, to prevent more attacks. With abortive drugs, early intervention is essential.

"Treat a migraine the moment you know an attack is coming. You wouldn't wait to treat asthma or diabetes," he stated. "Many studies show increased efficacy, improved patient satisfaction, and fewer side effects with early treatment of a migraine episode. But this needs to be balanced against medication overuse," Wenzel cautioned.

Level A evidence supports the use of dihydroergotamine, triptans, butorphanol nasal spray, and acetaminophen/codeine for episodic migraine.

"Although triptans are the treatment of choice according to the US Headache Consortium, only about 18% of current migraineurs use triptans," Wenzel said. "We need to improve patient uptake of triptans."

Although the US Food and Drug Administration issued an alert regarding the danger of the serotonin syndrome when triptans and selective serotonin reuptake inhibitors are coprescribed, Wenzel said this is not based on convincing evidence. "The alert was based on 27 cases and none of them had serotonin syndrome. Over 1 million people take these drugs concurrently without a problem," he stated.

Every patient with episodic migraine should have a back-up plan with another medication if his or her first medication is not effective.

New formulations of sumatriptan have been approved, including combination with naproxen, needleless injectable sumatriptan, and transdermal sumatriptan.

Preventive medications should be used only in patients with frequent and severe migraine. Strongly recommended preventive agents include divalproex sodium, sodium valproate, topiramate, metoprolol, propranolol, timolol, botulinum toxin A, and butterbur.

Behavioral or cognitive techniques may help decrease the frequency and severity of attacks.

Commenting on Wenzel's update on migraine, Gabriele-Monika Koschorke, MD, medical director of the Pain Clinic at the Southern Arizona Veterans Affairs Health Care System in Tucson, said, "This was a good comprehensive discussion from the pharmacological point of view. From a physician's point of view, neurologists will discuss different kinds of migraine as well as neurological disorders that can present with headache symptoms. Also, nonpharmacological options are important and should be given as much emphasis as drug treatment for the management of migraine."

Mr. Wenzel and Dr. Koschorke have disclosed no relevant financial relationships.

American Pain Society (APS) 32nd Annual Scientific Meeting. Presented May 8, 2013.

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