An expert neurologist explains how to decide on migraine treatment with a patient and when to consider preventive treatment.
David Kudrow, MD: How would I decide on treatment? How do I decide when to introduce preventive treatment for migraine? When do I use acute treatment for migraine? And is that a shared discussion with the patient? Let me start by saying that whether I’m prescribing an acute pharmacotherapy or a preventive therapy for migraine, it’s always a discussion with the patient. First, I find that patients who are informed are usually more compliant with the medication regimen. More information is better for everybody involved.
With respect to acute treatment for migraine, there are patients who have varying intensities or severities of migraine. Some patients can get away with using an over-the-counter medication for some of their migraines, or the same patient may have more severe migraines that require a more migraine-specific abortive agent. Everybody who has migraine should be armed with an acute migraine medication. With respect to preventive treatment, the bar is changing, which has to do with the recent introduction of migraine-specific, mechanism-specific medications that have a better adverse-effect profile and better efficacy. The American Headache Society is now recommending that patients who have even as few as 2 migraine days per month should be considered for preventive treatment if those migraine days are accompanied by significant disability, and any patient who has at least 4 migraine days per month, irrespective of the degree of disability, should be considered for migraine preventive therapy.
In my own practice, it’s a sliding scale. I have patients who may have 4 to 6 migraine days per month, and they’ve been using a triptan that works very effectively for them without much in the way of adverse events. They don’t want to take preventive medication and want to just keep using their acute medication. That’s a reasonable choice. On the other hand, there are patients who have 1 or 2 severe migraine days per month and are debilitated by them. Even if they use their acute medication, that medication may help the headache but then has adverse effects that incapacitate the patient or prevent them from working. Not many patients can tolerate losing 1 or 2 days of work per month without getting fired. If we can’t get those headaches under control with a good acute treatment, then even those patients should be considered for preventive therapy.
It’s always a discussion. Medications have adverse effects. I dread patients calling me and saying, “You didn’t tell me that I wasn’t going to be able to remember my kid’s name or that I was going to gain 20 pounds in the first month of taking this medication.” The discussion of when and whether to start a preventive treatment and which treatment that’s going to be is critical for the success of the therapeutic regimen.
Transcript edited for clarity.