SCOTTSDALE, ARIZ. – When it comes to triptan use in treatment of acute migraine, consider the maxim: Go big or stay home.
A high dose of a given triptan may be associated with an elevated risk for side effects; however, it also is more likely to be effective. Patients who do not respond to a lower dose given in the hope of avoiding adverse events are not going to come back to give the drug a second chance at a higher dose, Dr. Lawrence C. Newman said at a symposium sponsored by the American Headache Society.
“Studies generally show that the higher dose ranges are more effective for the triptans. We want to get treatment right the first time,” Dr. Newman said. Underdosing, he added, might cause a lack of efficacy and drive a patient to discontinue therapy or refuse another migraine-specific medication in the future.
A patient who experiences an adverse event, which is more likely at a high dose, will never take a triptan again, a meeting attendee observed. “I respect your opinion, but you are blurring the line between a preventive and acute medication,” Dr. Newman replied. “We find from acute studies that the higher doses are more effective. If I've had a patient try a medication at low dose for three attacks, and tell them I want to try the same medication for the next three attacks, they say no.”
Dr. Newman is director of the Headache Institute, St. Luke's-Roosevelt Hospital Center, New York City, and a consultant, adviser, and/or a member of the speakers' bureau for triptan manufacturers GlaxoSmithKline, Endo Pharmaceuticals, Pfizer Inc., Merck & Co., and Ortho-McNeil Inc.
Each triptan is available in different dosages, making it easy to reduce the dose if a patient experiences an adverse effect, Dr. Newman said. “Studies generally show … the side-effect profile does not differ significantly between the higher and lower doses.
There are currently seven triptans on the market, available in a number of formulations. All are available in tablet form, and some are available also as nasal sprays (sumatriptan, zolmitriptan), dissolvable wafers taken orally (rizatriptan, zolmitriptan), or injections (sumatriptan).
If headaches recur, treat attacks earlier, increase the dose, switch triptans, particularly to naratriptan or frovatriptan, add an NSAID, or switch to dihydroergotamine mesylate, Dr. Newman suggested.
“Do not give up on the triptan class because one does not work. There is evidence that some patients respond to one but not to another,” Dr. Newman said. “And treat at least two migraine attacks before switching medications.”
Because of the heterogeneity of migraines from one attack to another and between patients, patients need strategies to treat milder and more severe attacks, Dr. Newman suggested. “Give them a rescue medication so they don't have to call you at 3 in the morning.”
An optimal treatment plan goes beyond medication, Dr. Newman said. “Discussion needs to focus on lifestyle and behavioral modifications that include identifying and avoiding potential headache triggers, and [the importance of establishing] proper sleep hygiene and regular meal and exercise times.”
Early intervention is best. Patients need to manage their pain when it is mild. Patients may be treated 30 minutes into an attack when their pain is already moderate. Those who treat pain when it is mild use fewer medications, thus lowering the likelihood of rebound headache.
Dr. Newman recommended the Migraine Disability Assessment (MIDAS) questionnaire to gauge the degree of disability from the headache (Neurology 2001;56:S20–8). Patients with a higher-grade disability are much more likely to benefit from a specific treatment such as a triptan, compared with a general analgesic or NSAID.
The seven-item MIDAS questionnaire assesses days lost at school or work due to a headache, its impact on activities of daily living, headache frequency, and ratings of headache severity on a scale of 0–10. Other disability scales, such as the Headache Impact Test (HIT-6; Quality Metric Inc.), are also useful, Dr. Newman pointed out.
The MIDAS score, together with clinical judgment, ties in with a stratified care approach to migraine management. Low-end therapies include NSAIDS, analgesics, and triptans for so-called low-need patients who have infrequent but severe migraines. Consider combination analgesics, NSAIDs, antiemetics, triptans, and prophylactic therapy for moderate-need patients. Consider triptans, ergots, alkaloids, opioids, prophylaxis, and consultation for high-need patients. Other researchers validated the efficacy of such a stratified approach to management of migraine patients (JAMA 2000;284:2599–606).