Prevention
Patients presenting with more than 4 headaches per month, or headaches that last longer than 12 hours, require preventive therapy. The goals of preventive therapy is to reduce attack frequency, severity, and duration, to improve responsiveness to treatment of acute attacks, to improve function and reduce disability, and to prevent progression or transformation of episodic migraine to chronic migraine. Preventive medications usually need to be taken daily to reduce frequency or severity of the headache. The goal in this approach is 50% reduction of headache frequency and severity. Migraine preventive medications usually belong to 1 of 3 categories of drugs: antihypertensives, antiepileptics, and antidepressants. At present there are many medications for migraine prevention with different levels of evidence [49] (Table 5). Onabotulinuma toxin is the only approved medication for chronic migraine based on promising results of the PREEMPT trial [50].
Other Considerations
A multidisciplinary approach to treatment may be warranted. Psychiatric evaluation and management of underlying depression and mood disorders can help reduce headache frequency and severity. Physical therapy should be prescribed for neck and shoulder pain. Sleep specialists should be consulted if ongoing sleep issues continue despite behavioral management.
How common is nonadherence with migraine medication?
One third of patients who are prescribed triptans discontinue the medication within a year. Lack of efficacy and concerns over medication side effects are 2 of the most common reasons for poor adherence [51]. In addition, age plays a significant role in discontinuing medication, with the elderly population more likely to stop taking triptans [52]. Seng et al reported that among patients with migraine, being male, being single, having frequent headache, and having mild pain are all associated with medication nonadherence [53]. Formulary restrictions and type of insurance coverage also were associated with nonadherence. Among adherent patients, some individuals were found to be hoarding their tablets and waiting until they were sure it was a migraine. Delaying administration of abortive medications increases the chance of incomplete treatment response, leading to patients taking more medication and in turn have more side effects [53].
Educating patients about their medications and how they need to be taken (preventive vs. abortive, when to administer) can help with adherence (Table 6). Monitoring medication use and headache frequency is an essential part of continued care for migraine patients. Maintain follow up with patients to review how they are doing with the medication and avoid providing refills without visits. The patient may not be taking medication consistently or may be using more medication than prescribed.
What is the role of nonpharmacologic therapy?
Most patients respond to pharmacologic treatment, but some patients with mood disorder, anxiety, difficulties or disability associated with headache, and patients with difficulty managing stress or other triggers may benefit from the addition of behavioral treatments (eg, relaxation, biofeedback, cognitive behavioral therapy, stress management) [54].
Cognitive behavioral therapy and mindfulness are techniques that have been found to be effective in decreasing intensity of pain and associated disability. The goal of these techniques is to manage the cognitive, affective, and behavioral precipitants of headache. In this process, patients are helped to identify the thoughts and behavior that play a role in generating headache. These techniques have been found to improve many headache-related outcomes like pain intensity, headache-related disability, measures of quality of life, mood and medication consumption [55]. A multidisciplinary intervention that included group exercise, stress management and relaxation lectures, and massage therapy was found to reduce self-perceived pain intensity, frequency, and duration of the headache, and improve functional status and quality of life in migraineurs [56]. A randomized controlled trial of yoga therapy compared with self care showed that yoga led to significant reduction in migraine headache frequency and improved overall outcome [57].
Overall, results from studies of nonpharmacologic techniques have been mixed [58,59]. A systematic review by Sullivan et al found a large range in the efficacy of psychological interventions for migraine [60]. A 2015 systematic review that examined if cognitive behavioral therapy (CBT) can reduce the physical symptoms of chronic headache and migraines obtained mixed results [58]. Holryod et al’s study [61] found that behavioral management combined with a ß blocker is useful in improving outcomes, but neither the ß blocker alone or behavioral migraine management alone was. Also, a trial by Penzien et al showed that nonpharmacological management helped reduce migraines by 40% to 50% and this was similar to results seen with preventive drugs [62].
Patient education may be helpful in improving outcomes. Smith et al reported a 50% reduction in headache frequency at 12 months in 46% of patients who received migraine education [63]. A randomized controlled trial by Rothrock et al involving 100 migraine patients found that patients who attended a “headache school” consisting of three 90-minute educational sessions focused on topics such as acute treatment and prevention of migraine had a significant reduction in mean migraine disability assessment score (MIDAS) than the group randomized to routine medical management only. The patients also experienced a reduction in functionally incapacitating headache days per month, less need for abortive therapy and were more compliant with prophylactic therapy [64].