Patient Selection for Acute Migraine Therapy


Patient factors to consider when deciding on therapies to treat acute migraine.

Robert Cowan, MD, FAAN: The challenge is in figuring out which therapy to use for which patient. If you look at the International Classification of Headache Disorders diagnostic criteria, 2 people who have headache twice a week with some severe nausea and light and sound sensitivity will get the same diagnosis of episodic migraine. But 1 patient may respond very well to 1 medication, and another patient who has the same diagnosis may not respond to that medication at all, either because of adverse effects, comorbidities, or a variety of other factors. There is no 1-size-fits-all treatment. There is no universal first-line medication. It’s very customizable when it comes to the best treatment for each patient. 

We look at a number of factors. Someone whose headaches come on very quickly—for example, ramping up to a headache of 10 of 10 severity over 10 or 15 minutes—would want a medication that has a very fast maximum concentration and comes up very quickly in the blood supply. But typically, medicines that come on quickly wear off quickly. If someone has headaches that last 24 or 48 hours, a medication that comes on quickly may not be the ideal choice. Rather, a medication that may come on more slowly but lasts longer in the body may be a better choice.

Someone with cardiovascular risk factors may not want to use anything from the class of triptans because there may be a contraindication in that setting. When we think about preventives for patients with episodic migraine, we may not want to use a medication that has as an adverse effect of weight loss if someone is already having trouble keeping food down and maintaining their weight. For someone who’s having trouble staying awake all day, you may not want to give them a medication that has the adverse effect of sleepiness. It really depends very much on the patient and the presentation to determine which medication is best for which patient.

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