Treatment Goals for Acute Migraine


Dr Robert Cowan provides an overview of the burden, goals of therapy, and the pain freedom end point for acute migraine.

Robert Cowan, MD, FAAN: The burden of migraine is enormous. In the United States alone, there are about 60 million people with headache and about 40 million with migraine. Depending on whom you talk to, it costs the economy between $15 and 30 billion a year. The World Health Organization sees it as the second most disabling condition in the world, based on DALYs [disability-adjusted life years].

The goals for treatment of acute migraine are generally broken into 3 parts. The first is how we manage the acute event. The acute event is the onset of the various symptoms of migraine, including pain, nausea, light and sound sensitivity, imbalance, or other symptoms associated with migraine.

The second part of acute treatment is rescue, which is what you do if the acute treatment doesn’t work. The second component is prevention. Prevention consists of medications, devices, or certain behaviors that will reduce the likelihood of headaches occurring. It will reduce the frequency, severity, or duration of the headaches when they occur.

The third component is lifestyle changes. These are behaviors that you can incorporate on a consistent basis that will also make you more resistant to having headaches. These include regular sleep schedule, regular exercise, regular mealtimes, stress management, and other things like that.

There are a number of ways of assessing how effective a given treatment is for migraine. Generally, in the past we have used pain freedom, either at 2 hours or 24 hours. Another measure has been to look at reduction in pain at 2, 4, or 8 hours. Different studies have used different criteria for identifying how effective a medication is. Because not every study uses the same criteria, it’s very hard to compare them head-to-head. 

More recently, with some of the newer medications, another element has been added. That is the most bothersome symptom. Increasingly, we find that to be a very valuable measure for assessing how well a medication works, because not everyone considers pain to be their most bothersome symptom. For a lot of people, it’s the nausea, light sensitivity, or dizziness.

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