patient care perspectives

Risks Associated With Frequent Acute Migraines and Acute Treatment

by Paul G. Mathew, MD, DNBPAS, FAAN, FAHS

Overview

Frequent migraines and the frequent use of abortive/symptomatic treatment are associated with their own set of risks, including medication overuse phenomena and migraine progression. Our featured expert reviews the risks associated with frequent acute treatment and considers the role of preventive therapy in this context.

Expert Commentary

Paul G. Mathew, MD, DNBPAS, FAAN, FAHS

Assistant Professor of Neurology
Harvard Medical School
Boston, MA

“The saying ‘migraine begets migraine’ is accurate.”

Paul G. Mathew, MD, DNBPAS, FAAN, FAHS

The importance of migraine abortive treatment cannot be overstated. Migraine is more than just a headache; it often manifests as a disabling set of symptoms that can interfere with an individual’s ability to work and/or attend to family needs. Patients with migraine should have access to effective abortive therapies, and the timely use of such therapy can mean the difference between having a low-grade headache that resolves in 1 to 2 hours and having a moderate to severe migraine that can persist for multiple days. The 2 broad categories of acute treatment for migraine are migraine-specific agents (eg, triptans, gepants, dihydroergotamine, or ditans) and agents that are not specific to migraine but are nonetheless useful in relieving pain and/or other symptoms during an acute attack (eg, nonsteroidal anti-inflammatory drugs, acetaminophen, caffeine-containing compounds, butalbital, or opioids).

There are several pitfalls with acute treatments. First, there may be a false sense of safety associated with over-the-counter medications, which carry the risks of gastrointestinal impacts such as gastritis and bleeding ulcers, liver toxicity with chronic acetaminophen use, and renal toxicity with chronic nonsteroidal anti-inflammatory drug overuse. In addition, caffeine-containing drugs, butalbital-containing drugs, and opioids all have potential risks associated with their use, including medication overuse headache and sleep disruption. The former is of particular concern when medications are taken for more than 9 days per month. While effective, these drugs can lead to tolerance, until, eventually, headaches persist despite treatment.

For these reasons, migraine-specific medications are preferred in our practice. However, as with any medication, there are risks linked to these agents. Triptans are contraindicated in patients with comorbid coronary artery disease, a history of stroke, peripheral vascular disease, or uncontrolled hypertension. Triptan side effects including chest/throat tightness and a warm sensation are common, so it is reasonable to start with lower doses in patients who have a history of sensitivity to medications. 

As it relates to risks that may stem more directly from migraine frequency, the saying “migraine begets migraine” is accurate. Patients with episodic migraine without adequate treatment can progress to chronic migraine (>15 headache days per month), which underscores the importance of prevention. Stress, weather changes, hormonal changes, and sleep issues are all known triggers for migraine, but an effective preventative treatment can reduce the odds that such stimuli will all culminate into more migraine days. Migraine preventive treatments can often be useful in treating comorbid conditions, such as beta blockers improving high blood pressure or topiramate causing weight loss in a patient with obesity. We also have the first migraine-specific preventive therapies that target calcitonin gene-related peptide. The American Headache Society recently updated its position statement to include the use of novel therapies for preventing and treating migraine.

References

American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice [published correction appears in Headache. 2019;59(4):650-651]. Headache. 2019;59(1):1-18. doi:10.1111/head.13456

Buse DC, Greisman JD, Baigi K, Lipton RB. Migraine progression: a systematic review. Headache. 2019;59(3):306-338. doi:10.1111/head.13459

Kumar A, Kadian R. Migraine prophylaxis. StatPearls. Accessed January 21, 2021. https://www.ncbi.nlm.nih.gov/books/NBK507873/

Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E; Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society [published correction appears in Neurology. 2013;80(9):871]. Neurology. 2012;78(17):1337-1345. doi:10.1212/WNL.0b013e3182535d20

Thorlund K, Sun-Edelstein C, Druyts E, et al. Risk of medication overuse headache across classes of treatments for acute migraine. J Headache Pain. 2016;17(1):107. doi:10.1186/s10194-016-0696-8

Vandenbussche N, Paemeleire K, Katsarava Z. The many faces of medication-overuse headache in clinical practice. Headache. 2020;60(5):1021-1036. doi:10.1111/head.13785

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