Acute Migraine Treatment: “Stratified” Care

Contrary to widely held opinion, the headache disorder we term “migraine” is not clinically stereotyped. The symptoms of a migraine attack may vary dramatically between afflicted individuals, and even in a given individual symptoms may be quite different from attack to attack. While on Monday you may experience the severe, one-sided, and throbbing headache (with associated nausea and vomiting) typical of “classical” migraine, Saturday’s migraine attack instead may involve a dull, generalized, and low-intensity headache absent any nausea but accompanied by the visual symptoms known as “aura.” The attacks’ symptoms are quite different – the headaches themselves are quite different – but both attacks are “migraine.”

Not only do the symptoms of migraine tend to vary from attack to attack, but even within a single attack there may occur a progression of symptoms. Acute migraine is dynamic, both in terms of symptomatology and the biologic process that produces those symptoms; if that process is allowed to progress unchecked for too long, the symptoms it generates can become quite difficult to treat.

The concept of stratified care acknowledges the dynamic nature of an evolving migraine attack, and use of a stratified care approach to treatment of acute migraine implies that one selects his/her therapy based upon the headache’s intensity and the presences vs absence of associated symptoms (eg, nausea and vomiting).

Very few migraineurs find that a single medication or alternative therapy is effective for all their migraine headaches. For example, “three aspirin and a cup of coffee” may represent perfectly appropriate (and effective) therapy for early/mild migraine, but this treatment makes little sense if the headache is severe and accompanied by vomiting.

For the migraineur’s therapeutic arsenal, it is often ideal to have two or three different therapies available for acute migraine treatment: (1) something for early/mild headache; (2) something for headaches that have escalated despite treatment with #1 or that have escalated rapidly to become moderate to severe (eg, “full-blown” migraine already present upon awakening); and (3) a “rescue” therapy if #2 fails.

With this “stratified” approach, you hopefully will find yourself far more capable of controlling your acute migraine attacks.

John F. Rothrock, MD

University of Alabama,

Birmingham, AL, USA