Treatment of Migraine: Acute vs Preventive
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Recently in my clinic, a young woman whom I’d initially seen six weeks prior for frequent episodes of migraine returned for follow-up. At the initial visit, I prescribed medication X for headache prevention and medication Y for “as needed” treatment of acute headache. I spent about 15 minutes discussing with her precisely how to use the medications I’d prescribed. To supplement that conversation, I provided her with hardcopy educational materials regarding migraine and its management, along with electronic access to additional materials relevant to her headache disorder. On her prescriptions, I specified that medication X was intended “for headache prevention.” In contrast, medication Y was intended “for acute headache treatment.”
At the return visit, the patient told me that she was no better. She reported that the nine tablets of the medication I prescribed for headache prevention had lasted only nine days. When she sought a refill, her pharmacist had advised her it was “too early.” Furthermore, she told me, the 30 tablets of medication I had prescribed for acute headache treatment had failed to help on the 4 or 5 occasions she tried it.
In other words, despite my efforts to ensure that she would understand how to use the medications I’d prescribed, this intelligent and articulate young woman used a medication intended for acute headache treatment as a prevention therapy and medication intended for prevention therapy as an acute treatment. This particular error is by no means uncommon, and it reflects all too well the misunderstandings that complicate the efforts healthcare providers, and their patients make to communicate accurately with one another.
Do You Need Migraine Prevention Therapy?
This typically is the key question you must address in constructing an appropriate strategy for managing your migraine. While it’s a given that most migraineurs who present to a healthcare provider for evaluation of their headache disorder will require at least one medication for acute headache treatment, not all patients need a course of prevention therapy for migraine stabilization. To answer this key question, ask yourself the following: What is my current headache migraine burden?
This “burden” can be surprisingly difficult to measure, and in the next article of this issue, we will address migraine burden in detail. For now, however, assume that your burden has increased to the point that your acute therapies are not enough; you are finding them to be less effective, are afraid you are using them too often, or both. You wish to know what is available for headache prevention.
The ideal migraine prevention therapy would be simple to administer, cause no side effects, produce freedom or near freedom from headache within a short time following initiation of treatment. It also would render such headaches that occur less severe and more easily terminated with acute therapy. And finally, it would suppress the brain’s migraine circuitry so effectively that the therapy eventually could be discontinued without the patient experiencing any consequent increase in headache burden.
While some lucky patients do achieve this result from the first prevention therapy they are prescribed, the majority do not. Identifying an effective prevention therapy is a process of trial and error, and this can be frustrating for both you and your provider. Not infrequently, the first treatment chosen is ineffective, only partially effective or impossible for the patient to tolerate due to side effects. The second may be no better. Or
the third.
Stick with it! Find a provider you trust and with whom you can communicate easily. Educate yourself about the therapeutic options available to you and, in particular, the option you decide upon. Administer the therapy as prescribed, and if you are experiencing possible side effects or no headache relief, contact your provider. Don’t simply stop the treatment. In some cases, the side effects will fade with time and continued treatment. In most cases, weeks will be required before you will notice any definite improvement.
The odds are high that you will experience “break-through” headaches even when you are using effective prevention therapy. Treat those acute headaches aggressively! Just as a severe, prolonged migraine episode may predispose to yet more headache, early and effective termination of an episode using an acute therapy may have a prevention effect, reducing the likelihood of early headache recurrence. As always, when treating acute migraine headache, have multiple “lines of attack” available to use, and match your therapy to the headache intensity.
Whether your treatment regimen involves therapy for acute migraine only or a combination of acute therapy plus prevention therapy, communicate with your provider if you feel things are not going well. There are far too many options for migraine management now available to justify enduring a lukewarm therapeutic response or simply giving up altogether.
