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MIGRAINE: TREATMENT

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Rahimtoola H, Buurma H, Tijssen CC, Leufkens HG, Egberts AC. Migraine prophylactic medication usage patterns in The Netherlands. Cephalalgia. 2003;23:293-301.

This study aims to investigate usage patterns of specific migraine prophylactic medications in ergotamine and triptan patients commencing this treatment for the first time during 1 January 1992 until 31 December 1998. Usage patterns of specific migraine prophylactic drugs were evaluated for each patient by accessing data from a large prescription database and were characterized as continued, switch or stop use during the patient observation period. Several patient and medication-related factors were explored in order to identify a possible relationship with the specific usage pattern defined. Approximately 75% of the study population (n = 729) had terminated (stop or switch) prophylactic treatment after 1 year. Age <40 years (relative risk (RR) 1.9; 95% confidence interval (CI) 1.2-3.2) and the concomitant use of non-steroidal anti-inflammatory drugs (RR 3.2; 95% CI 1.2-5.5) or specific abortive migraine drugs resulted in a faster onset of treatment modification (switch). Overall, migraine prophylactic treatment is used for a relatively short period, probably attributable to the common limitations associated with migraine prophylaxis, such as poor compliance and/or limited therapeutic efficacy. Patterns of use can be influenced by a variety of factors, including age, type of prescriber and certain co-medication. Patient interview studies are required to clarify these issues further.

Comments.—No practicing clinician should be surprised by the findings of brief use by patients of migraine preventive medications with poor compliance. The standard for preventive medication for migraine currently is about 50% of patients showing a 50% reduction in migraine frequency. This finding is often demonstrated in “enriched” studies, first used in the divalproex prophylaxis studies, in which all subjects were placed on placebo for a 1-month run-in, and those “most suggestible” subjects, that is, those who responded to the first month of placebo, being excluded in the 2- to 3-month placebo-controlled trial of preventive medication which followed. Even with this approach, placebo effect can extend to 3 months. There is often a long-term regression to the mean, and, therefore, interpretation of preventive trials is sometimes difficult. With methysergide off the market in the United States, we have no medication specifically designed for migraine prevention, and a designer preventive medication is currently the most significant need in migraine care. SJT

The new holy grail for migraine treatment must now be the search for an effective prophylactic treatment. Given the difficulties faced by a number of pharmaceutical companies (eg, Abbott in the United States) in convincing the regulatory authorities, such as the Food and Drug Administration, of robust efficacy and safety, the road ahead is likely to be difficult, but, nevertheless, rewarding for those with the experience and dedication to address this large unmet medical need. DSM
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Document Type: Research Article

Publication date: April 1, 2004

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