Study assesses best treatments to use when a migraine attack occurs

Dr Marmura

It is important to ensure established migraine medications are available for the patients who need them, according to a new study published in the January issue of Headache. 

Researchers reviewed recent scientific literature and concluded that a number of classes of drugs were effective for treating acute migraine. The assessment will form the basis of new American Headache Society (AHS) treatment guidelines.

The review focused on the evidence for acute migraine treatment, using large placebo-controlled clinical trials as the foundation for best practices. Multiple new medications are now established as effective for migraine since the last guidelines in 2000 including migraine-specific medications, such as triptans (almotriptan, eletriptan, frovatriptan, zolmitriptan), and the combination of sumatriptan and naproxen. 

“In addition other medications for pain such as ibuprofen, diclofenac are effective, as well as acetominophen for mild-moderate migraine,” said one of the study’s authors Michael J. Marmura, MD, a specialist in neurology at the Jefferson Headache Center of Thomas Jefferson University.

The authors, who are members of the Guidelines Section of AHS, updated the acute migraine treatment guidelines published in 2000 by the American Academy of Neurology (AAN) and the AHS. They used AAN Guidelines Development Procedures to conduct a thorough review of recent scientific literature on this topic. The AHS and AAN also recently published joint guidelines on the prevention of migraine attacks.

“Multiple other medications are listed as probably or possibly effective for migraine,” said Dr Marmura. “Some older medications, including opioids such as methadone, codeine and meperdine were downgraded to ‘possibly effective’ due to lack of high-quality evidence in clinical trials.”

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According to Dr Marmura, many established medications, such as most triptan formuations, are not generic and more expensive.

“Sometimes these medications are denied or doctors prescribing these medications often need to complete prior authorizations. Opioids and barbituate-containing drugs, on the other hand, are generally inexpensive but have less evidence for migraine,” he said.

“In fact the long-term prognosis of migraine for patients who frequently use either opioids or barbituates is very poor, and can lead to dependence or addiction,” said Dr Marmura. “Patients who can't get preferred medication and use opioids or barbituates may suffer negative outcomes for the migraines they suffer and down the road.”

It is important to note that most of these studies include patients with migraine in the outpatient setting, according to Dr Marmura. “The treatment of acute migraine in the emergency room and in the hospital may be different, but I think it is important to have multiple Level A options available on the hospital formulary,” he said.

“Of course every person with migraine is different and clinicians who treat migraine need to assess the clinical situation,” said Dr Marmura. “For example, someone with migraine who often has severe nausea or vomiting may not do well with an oral drug. Chronic migraine sufferers and those with prolonged migraine in the emergency room may not do well with usual treatment.”

This review also reflects the changing nature of clinical guidelines from expert opinion to evidence-based studies.

“This can create some confusion,” conceded Dr Marmura. “For example, acetaminophen oral is considered effective for mild-moderate migraine attacks based on large placebo-controlled trials with hundreds of patients. Intravenous acetaminophen is listed as possibly ineffective based on a small study of 60 patients with severe migraine attacks. As an expert, I would guess oral acetaminophen is not superior to intravenous in reality but there is no clinical evidence to support this belief.”