The evolving management of migraine

December 04, 2003

NEW YORK--Therapy to prevent migraines can be more effective than attempting to treat pain after the migraine process has begun, according to Stephen D. Silberstein, M.D., director of the Jefferson Headache Center and professor of neurology at Thomas Jefferson University in Philadelphia, and president-elect of the American Headache Society.

"Migraine treatment has come a long way in the past five years," Dr. Silberstein said. He explained that the key factor in treatment advances is the development of triptans, drugs that are capable of combining with neuronal receptors in the brain to initiate drug actions. Dr. Silberstein spoke in New York today at an American Medical Association media briefing on advances in neurology .

About 25 to 30 million Americans experience migraine headaches and many more are undiagnosed. Migraine is more prevalent in women: 18 percent of women and six percent of men (12 percent of the overall U.S. population) are affected by migraine headaches. The annual cost of migraine is 17 billion dollars in health care and lost labor costs in the United States alone. Dr. Silberstein commented that some patients who have episodic (occasional) migraines (the most common) eventually develop chronic migraines (those that occur more than 15 days per month; occurs in 2 percent of patients.) There are many risk factors for chronic migraine, Dr. Silberstein said, such as obesity, snoring, stressful life events and overuse of pain medications, among others.

Patients often unwittingly aggravate the frequency and severity of their migraine by taking too much acute medication, causing medication overuse headache. The International Headache Society has recently released guidelines that define overuse of acute medications as the use of opioids, triptans or combination analgesics for more than 10 days per month or simple analgesics (pain relievers such as aspirin or ibuprofen) for more than 15 days per month.

"One of the greatest bugaboos we see every day in headache centers is patients with chronic daily or near-daily headache, who are overusing medication--it is our most common problem," Dr. Silberstein said. "These patients have often not responded to treatment and in an attempt to treat themselves, actually make the problem worse. This is not addiction or an attempt to get 'high'; rather, it is motivated by the patient's desire to relieve pain and dysfunction."

The focus of treatment has shifted in recent years, Dr. Silberstein said. "Acute treatment consists of taking medication when the migraine starts; prophylaxis (preventive) therapy is aimed at taking medication daily to prevent migraine altogether," he explained. "Migraine preventive therapy is grossly underused."

The focus of prevention, according to Dr. Silberstein, is to reduce attack frequency and severity, improve response to treatment, improve function and disability, reduce the use of acute medications and the risk of medication overuse, prevent the disease from worsening and reduce health care costs.

"The tragedy is that 53 percent of patients with migraine meet the criteria (according to the frequency and severity of their headaches) for preventive treatment, but only five percent actually use preventive therapy," Dr. Silberstein noted. A recent study of patients who were transitioned from acute therapy to combination acute and preventive therapy showed dramatic results. "Office visits declined by more than one half, emergency department visits decreased by 82%, CT scans decreased by 75%, MRI scans decreased by 88% and medication costs decreased by $48 - $138/month/patient.

Dr. Silberstein commented that topiramate, a drug previously used for seizures in patients with epilepsy, has afforded new treatment options. In a recent study, half of the patients treated with topiramate had a 50 percent reduction in the frequency of migraines, 27% had a 75 to 90 percent reduction in headaches, and migraine headaches were completely eliminated in 6% of topiramate-treated patients. He cautioned that 5 percent of the study patients experienced side effects such as a pins and needles sensation in the hands and feet, anxiety, fatigue, nausea, stomach pain, memory problems and insomnia. Topiramate is expected gain final approval as a migraine treatment in 2004. Another new type of treatment involves injection with botulinum toxin. This treatment is used for dystonia (involuntary movements) and spasticity, and has recently been shown to be an effective migraine preventive therapy.

"The problem of headache is extraordinarily common--about 4 percent of the world population have daily headache," Dr. Silberstein concluded. "Hopefully, we can relieve the pain and suffering of people everywhere with new treatments and discoveries."
CONTACT: Stephen Silberstein, M.D., call Jeffrey Baxt at 215-955-5507. On the day of the briefing, call the AMA's Science News Department at 312-464-2410.

American Medical Association

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