Peter Goadsby, MBBS: In my practice as a headache neurologist, I am frequently manipulating triptans because patients have had simple analgesics and nonsteriodals. I’m looking for the best triptan in an individual, which can depend on the speed of response, adverse effects and recurrence. I’m pairing the triptan typically with naproxen to try and increase the efficacy while reducing headache recurrence. On the preventive side, I’m looking to match the patient to the adverse effects in multiple ways because most of the preventives have a variety of adverse effects. What I find myself doing is setting out the adverse effects and having a discussion with the patient about which is least bothersome.
Richard B. Lipton, MD: There are a large number of evidence-based acute treatments for migraine; 7 triptans are approved by the FDA in the United States, only 1 of which is a nonsteroidal anti-inflammatory. There are also a number of combination analgesic products that are FDA approved in addition to some simple analgesics, including a number of ibuprofen preparations that are FDA approved for migraines.
When it comes to choosing an acute treatment for migraine, the first issue is: how severe are the attacks and how frequently do they occur? If the attacks are infrequent and relatively mild, some of the over-the-counter medications may suffice to manage pain—particularly if they take the acute treatment early in the attack while pain is mild. For other patients with severe attacks, triptans are a great option. All of the triptans are available orally, but some of them are available through non-oral routes of administration. Those non-oral routes of administration are particularly important in several groups of patients.
If a patient regularly vomits early in the attack, oral medications are obviously ill-advised; however, even in patients without severe nausea, they may not be able to take an oral pill or find it difficult to absorb the medication. People think of treatment effects beginning when the patient puts the pill in their mouth—but the reality is the treatment begins to work when the drug reaches its critical levels at the active site where it works. If the drug is not absorbed, it can’t work. There are several injectable and nasal-spray formulations of sumatriptan—and the better nasal sprays are most quickly absorbed.
There’s also a nasal spray formulation of zolmitriptan, as well as many other offers underway to find ways of getting drugs into people’s bodies during a migraine attack, circumventing the gut. Again, that’s important in the subgroup of patients who have gastric paresis—whose digestive system is paralyzed and who might not be able to absorb the drug well during the attack.
Stephen Silberstein, MD: I pick a medicine depending on the patient’s age, and whether they’re of childbearing potential, what they have taken in the past, and medical complications. The 2 major choices are nonsteriodals alone or in combination with a triptan, and then something like Compazine for a rescue medicine in case the headache doesn’t come under control.
Peter Goadsby, MBBS: For preventive treatments, I first establish the intolerable therapies for an individual, since there’s no point in offering ineffective methods. I’m not going to offer beta blocker or propranolol to someone who has asthma, for example, or topiramate to someone who has a history of kidney stones. Afterward, it’s useful to set out some choices and let the patient decide which one they want to take because the chances are they’ll take the medication if they make the decision. The crucial thing in prevention—and it’s true of all migraine therapy—is to make sure the patient is an active participant in the decision that you’re taking so they understand why they’re choosing this line of treatment.