Treatment Options Are Increasing for Migraines

Migraines are the most common type of headache, and approximately 14% of Americans have them, costing up to $13,000 per patient annually in lost work time and productivity.^1-3

Women experience migraines roughly 3 times as much as men.¹ Patients who have migraines typically self-treat until OTC medications no longer work.

Then they visit a primary care provider (PCP) and eventually may need to see a specialist.⁴

DIAGNOSTIC CHALLENGE

Migraines are tricky. They can present with or without aura, occasionally are bilateral, and at other times may be felt at a different spot in the head.⁵ PCPs struggle to diagnose migraines because patients often report different clinical presentations over time. Additionally, many providers cannot isolate patients’ specific risk factors, such as fatigue, lack of sleep, mental tension, missed meals, and stress. Also difficult to isolate are triggers such as alcohol, changes in altitude or barometric pressure, light, menstruation, noise, odor, physical activity, smoking, and vasoactive substances in food.⁶

Pathophysiologic changes in the central nervous system (CNS), rather than the vascular system, seem to precipitate migraines.1 When the pain pathway is stimulated, the CNS releases messenger molecules, including calcitonin gene-related peptide (CGRP), nitric oxide, and serotonin.¹ Thus, migraines are a neurological condition.

Because 70% of those who develop migraines have a first-degree relative who also has migraines, a genetic component is likely.¹

Migraines can be chronic (occurring more than 15 days per month) or episodic (occurring fewer than 15 days per month). The index of suspicion for migraines rises when patients report at least 2 of the following criteria: light or sound senstivity, moderate to severe head pain, nausea or vomiting, pulsating pain quality, and unilateral or 1-sided pain.

Table 1^1,7 describes a migraine’s typical presentation.

Approximately one-third of individuals with migraines report aura, which is a language, motor, neurologic, sensory, speech, or visual disturbance lasting 5 to 60 minutes that signals a headache is starting.⁵ Some individuals experience depression, fatigue, food cravings, hyperactivity or hypoactivity, neck pain or stiffness, or yawning before a migraine (called a prodrome). These symptoms may also persist after the migraine resolves (called a postdrome).¹

Some acute migraines respond to the patient resting in a dark room and applying cold packs with pressure to the forehead or temple areas.¹ Table 2^8-16 lists medications for migraine management.

CLINICAL PEARLS

The American Headache Society’s Choosing Wisely recommendations indicate that butalbital-containing medications or opioids are not first-line interventions.¹⁷ Frequent, prolonged use of OTC pain medications is unwise because patients can become tolerant to specific drugs’ analgesic effects, magnifying migraine frequency and intensity. For these patients, detoxification may be necessary, and the migraine may worsen during the withdrawal period.¹⁷

Preventive treatment helps patients who are unresponsive to or cannot tolerate abortive therapies or have recurring migraine attacks that interfere significantly with quality-of-life.¹ Just one-third of patients who could benefit from preventive migraine treatment receive them. Discontinuation rates are also quite high once patients start prophylaxis.¹⁸ Preventive drugs with the strongest evidence supporting their

use are anticonvulsants divalproex sodium and topiramate; β-blockers metoprolol, propranolol, and timolol; and frovatriptan for short-term prevention of migraines associated with menstruation.¹⁹ CGRPs and onabotulinumtoxinA also are approved for prevention.

Women who experience migraines with an aura should not take contraceptives containing estrogen.⁵ They have a 2-fold increase in the risk of ischemic stroke compared with women whose migraines are without an aura, and estrogen supplementation increases this risk.²⁰

CONCLUSION

Patients who have migraines may turn to pharmacists first. Pharmacists need to engage patients in conversation and encourage them to ask their prescribers about newly approved preventive therapies when appropriate.

Jeannette Y. Wick, RPh, MBA, FASC, is the assistant director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy in Storrs.

REFERENCES

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