Abstract
Our understanding of migraine has improved greatly over the past decade, and the array of treatments that are currently available can minimize the pain and disability suffered by affected patients. Yet treating migraine effectively remains a challenge, and many patients continue to suffer unnecessarily. Although the reasons for this are not always clear, it is becoming apparent from mounting evidence that the approach to the management of migraine needs to be critically re-appraised. This supplement will address this issue and aims to raise awareness about how to overcome some of the current barriers to achieving an optimal outcome that are commonly encountered in routine daily practice.
In the following articles, the fundamental role that general practitioners play in migraine management will be considered in terms of ensuring that patients have a positive first experience when seeking treatment for migraine. However, there are occasions when headache symptoms can be sufficiently severe that they require treatment in an emergency room setting. This supplement will also consider the reasons for this and suggest a paradigm to minimize the risk of migraine patients getting to this stage. We know, for example, that the migraine-specific medications, notably triptans, are not being used to their full potential in the treatment of migraine. This may be because the decision to progress beyond simple analgesics and non-steroidal anti-inflammatory drugs to migraine-specific medication is based on a well-established ‘one-size-fits-all’ trial-and-error paradigm, rather than a patient-specific approach based on the severity of presenting symptoms. An article in this supplement will show that by closing the time gap between non-specific analgesia and the first use of triptans, patient expectations are more likely to be achieved. The choice of medication is also crucial to meeting patient expectations, and a pharmacogenomic approach, described in this supplement, can assist in making informed decisions to enhance treatment success.
The timing of treatment intake in relation both to the time of onset of a migraine attack and the intensity of pain at the time of medication intake can profoundly affect treatment outcome. Interpretation of the results of studies to investigate the potential benefits of early treatment are, however, constrained by difficulties in distinguishing between early and mild pain, which are not always synonymous terms in migraine. A milestone study, the ‘Act when Mild’ Study, has recently clarified the picture by identifying a window of opportunity to achieve optimal outcomes. This study, which will be described in this supplement, has shown that treatment with almotriptan within 1 h of pain onset and while migraine pain is still mild provides clinically important enhancements in efficacy compared with a more traditional approach of waiting until pain has increased in intensity before medication is taken. In recognition that clinical trials do not always reflect routine clinical practice, several case studies will be presented in this supplement to illustrate scenarios where the benefits of the ‘Act when Mild’ paradigm can be successfully applied to clinical practice.
This supplement will provide both scientific evidence and practical suggestions that will assist physicians in helping patients achieve the best possible outcomes from their currently available migraine treatments.
Competing interests
D.V. is a paid consultant and has received fees for speaking from Almirall, GlaxoSmithKline, Menarini, MSD and Pfizer.