Further support for this recommendation is found in a well-designed retrospective study demonstrating that the rate of significant intracranial pathology (mass lesion or hemorrhage) in patients presenting to primary care practices with a new headache and no neurologic findings was only 0.35%.11 Some patients and physicians will find even this low risk unacceptable and will obtain neuroimaging studies for reasons (such as litigation fears, risk perception, and so forth) that likely are not amenable to statistical argument.
TABLE 1
DIAGNOSTIC CRITERIA FOR MIGRAINE
Migraine Without Aura
|
Migraine With Aura
|
| In both cases, the diagnosis of migraine cannot be made if the history or physical examination suggests another disorder unless that disorder has been ruled out by appropriate testing or the migraine attacks do not occur for the first time in close temporal relation to the disorder. |
| Adapted, with permission, from Headache Classification Committee of the International Headache Society. Diagnostic Criteria. Available at: http://www.i-h-s.org/ihsnew/guidelines/pdfs/diagnost.pdf. Accessed May 28, 2001. |
TABLE 2
DIAGNOSTIC FEATURES IN MIGRAINE
| Finding | Sensitivity (%) | Specificity (%) | LR+ | LR- | PV+% (M/F) | PV-% (M/F) |
|---|---|---|---|---|---|---|
| Versus Patients With Tension-Type Headache | ||||||
| Nausea | 81 | 96 | 19.2 | 0.20 | 56/82 | 1.2/4.2 |
| Photophobia | 79 | 86 | 5.8 | 0.25 | 26/55 | 1.5/5.1 |
| Phonophobia | 67 | 87 | 5.2 | 0.38 | 25/53 | 2.4/7.7 |
| Exacerbation by physical activity | 81 | 78 | 3.7 | 0.24 | 19/45 | 1.5/5.1 |
| Unilateral location | 65 | 82 | 3.7 | 0.43 | 19/44 | 2.7/8.6 |
| Throbbing or pulsating quality | 73 | 75 | 2.9 | 0.36 | 16/39 | 2.2/7.3 |
| Precipitated by chocolate | 33 | 95 | 7.1 | 0.70 | 30/59 | 4.3/13 |
| Versus Patients Without History of Headache | ||||||
| Family history of migraine | 58 | 88 | 5.0 | 0.47 | 24/51 | 3.0/10 |
| LR+ denotes positive likelihood ratio; LR-, negative likelihood ratio; PV+, probability of migraine given a positive finding; PV-, probability of migraine given a negative finding. | ||||||
| Prevalence of migraine in the US population is 6% for men (M) and 18% for women (F).1 | ||||||
| Adapted, with permission, from Smetana GW. The diagnostic value of historical features in primary headache syndromes: a comprehensive review. Arch Intern Med 2000; 160:2729-37. ©2000 American Medical Association. | ||||||
Treatment
General principles
Although the diagnostic criteria for migraine are relatively straightforward, the expression of these symptoms can be highly variable, both between patients and in any given patient between attacks. In addition, patients with migraine often experience intercurrent tension or other primary headaches, complicating both the diagnosis and the interpretation of response to a therapeutic trial. Consequently, finding the right medication for an individual is often challenging. The choice of treatment may be suggested or limited by coexisting conditions. The presence of severe nausea or vomiting during a migraine may require use of a medication that can be dosed other than by mouth.
Patient education and involvement in the development and evaluation of a migraine treatment plan is essential. Just as migraine sufferers differ in the type, frequency, and severity of their symptoms, they also differ in their treatment preferences and goals. Some are unable to tolerate certain side effects; others are more interested in rapid relief of pain. Discussions regarding expected responses to treatment can prevent patients’ disappointment and losing patients to follow-up. For example, a reduction in the frequency of headaches over the course of several months is a more realistic goal than immediate prevention of all headaches. A patient’s headache diary can aid the patient in identifying and possibly eliminating migraine triggers and greatly assist the physician in adjusting and refining a treatment plan.
Various treatments, both pharmacologic and nonpharmacologic, have been used to treat patients with migraine. This article examines treatments in 3 categories: abortive medications, prophylactic medications, and nonpharmacologic treatments.
Abortive medications
Table 3 lists over-the-counter (OTC) and prescription medications for acute migraine attacks. Until recently, little if any high-quality evidence existed to guide the physician in selecting the appropriate medication for a specific patient. The USHC issued a consensus recommendation that nonsteroidal antiinflammatory drugs (NSAIDs) and over-the-counter analgesics be considered first-line treatments, especially for mild migraine headaches, and that migraine-specific agents be used for patients with more severe episodes.12
Further support for this stratified-care approach to migraine treatment has since been provided by the Disability in Strategies of Care (DISC) Study. DISC demonstrated that patients whose treatment was chosen according to their Migraine Disability Assessment Scale (MIDAS) score (those with a score of I or II were treated with aspirin and metoclopramide; those with a score of III or IV were treated with zolmitriptan) had less disability and a significantly greater headache response at 2 hours than patients who were given zolmitriptan if their headaches failed to respond to aspirin and metoclopramide.13 The study supports the expert consensus that patients with a history of mild disability associated with migraine can be treated effectively with simple OTC analgesics, whereas patients with significant migraine-associated disability will have better outcomes if treated with migraine-specific medications (LOE: B).