Different options are available to stop migraine attacks: acute, symptomatic treatment. According to recent clinical evidence, the common approach to treating a migraine attack is based on early intervention when the pain is still mild, which can result in shortening the time to achieve a pain-free response.
Acute therapies are generally divided into two categories: non-specific treatments, such as paracetamol (acetaminophen), nonsteroidal anti-inflammatory drugs (NSAIDs, including aspirin [
23]), opioids and combinations of analgesics, these are usually the first choice for the treatment of mild or moderate migraine attacks; and specific anti-migraine treatments, including ergotamine and the triptans, including almotriptan, naratriptan, sumatriptan, zolmitriptan, etc., which are usually first-line drugs for the treatment of severe migraine attacks.
Almost all guidelines consider ergotamine effective and favorable for the treatment of migraine due to its low relapse rate, but because of its poor tolerability and an increased risk that it might induce overuse headache, some guidelines recommended ergotamine as a second-line treatment (EFNS and Germany, Level B), while others do not recommend it at all (Scotland, Level A).
A key aspect of the guidelines is the type of approach recommended for the acute treatment of migraine.
Stratified versus stepped care
Some guidelines recommend a stepwise approach to the treatment of migraine [European Headache Federation (EHF), UK and Scotland]: initially acute attacks are treated with the safest, least expensive therapies and migraine-specific medication is only used if the initial treatment fails. Others guidelines recommend a stratified approach (EFNS, Italy), which is based on severity of illness and matches the patient’s needs to the characteristics of the migraine (severity, frequency, disability, symptoms, time to peak); this approach recommends migraine-specific drugs for severe attacks.
The arguments in favor of stepped care are that the treatment decision is simple, guidelines are more defined, and patients receive different treatment options in order to find the most appropriate one. However, the disadvantages are that the time until patients receive their optimal medication can be protracted, patients are not involved in the treatment decision and they may become lapsed consulters if they are not receiving effective medication. In the stratified management approach, patients are involved in the treatment decision and more will be exposed to migraine-specific treatment. However, possible disadvantages of stratified care are that clear and straightforward counseling about medication is needed, treatment choice requires careful consideration of clinical evidence, and patients may have unrealistically high expectations.
The question of which approach is the best is still unresolved. Some national guidelines within Europe do not specify the approach to be followed. For example, in the Croatian guidelines the choice of acute treatment is based on migraine characteristics and in Germany detailed information is supplied for each pharmacotherapeutic group, but neither state a preference for stepped or stratified care.
Lipton and colleagues [
25] conducted a prospective study in which they showed that the stratified care approach provides the optimal clinical outcome, and a post hoc analysis suggested stratified care was associated with lower costs compared with other approaches [
26]. Furthermore, Silberstein et al. [
27] recommended stratified care with the use of triptans in patients who have moderate or severe migraine, or whose mild-to-moderate migraine responded poorly to NSAIDs, in an evidence-based guideline for the treatment of migraine.
It is possible that guidelines influence the chosen treatment strategy, and that prescriptions for migraine medication correlate with the availability of guidelines. Evaluating patterns of acute migraine management in the population is an important step to assess treatment according to guidelines and to improve the quality of care.
In the Maze study (migraine and zolmitriptan evaluation), MacGregor et al. [
28], showed that analgesics were the most common treatment prescribed for migraine, and an average of only 10% of subjects were prescribed triptans; ranging from 3% in Italy to 19% in the USA. These data have recently been confirmed in studies performed in the same countries [
29,
30]. The tendency to prescribe triptans more frequently in some countries, such as Germany and the USA, may be because triptans are the first-line recommendation for treating migraine in the German and American guidelines. However, one could speculate that the tendency to prescribe triptans more frequently in these countries may be that other countries do not have, or do not adhere to, national guidelines.
Although these data are not directly linked to the availability and use of guidelines, they do provide information on the proportion of prescriptions written for the different types of agent in different countries, and the available guidelines will have an effect on what is prescribed. However, the use of guidelines requires further consideration in terms of whether or not their availability influences treatment strategies, or if they can be used to modify physician behavior with respect to treatment and thus improve patient outcomes.
The target audience for guidelines generally involves primary care physicians (EHF, Switzerland) or neurologists/headache specialists (EFNS, Croatia, Italy, Romania), although in other countries they are intended for all healthcare professionals who manage headache (France, Scotland, Spain, UK). While many factors may be involved, it is possible that headache specialists are more aware of the guidelines available and this may influence their prescription choice. There may be a need to target guidelines to different audiences, or a need to ensure that guidelines are disseminated not just to specialists, but also to primary care physicians.
Moreover, from 2006 some triptans (naratriptan 2.5 mg and sumatriptan 50 mg) were approved in the UK and Germany as over-the-counter (OTC) drugs. This availability might increase the use of triptans in clinical practice and may also encourage patients to treat their migraine symptoms earlier.