WASHINGTON– The combination of optimized acute medication, preventive medication, and behavioral therapy significantly reduced migraine activity, according to study results presented at the annual meeting of the American Pain Society.
In a study of 232 patients with frequent, disabling migraine, Kenneth A. Holroyd, Ph.D., distinguished professor of psychology at Ohio University in Athens, and his colleagues assessed the effectiveness of optimal acute therapy (OAT); OAT plus preventive medications; OAT plus behavioral migraine management; or OAT plus a combination of preventive medications and behavioral migraine management.
All treatments reduced the number of migraine episodes. However, neither preventive medication nor behavioral management in combination with acute medication made a significant difference. But the combination of all three–preventive medication, behavioral therapy, and acute medication–caused a significant improvement in outcome, Dr. Holroyd said.
Potential participants met the International Headache Society criteria for migraine. They had to have a minimum of three migraines per month with significant migraine-related disability. Individuals with medication overuse complications were excluded. Patients who met these criteria completed a 5-week run-in period of acute therapy (triptans, NSAIDs, antiemetics, and rescue medications as needed).
Most of the participants were women (79%). The average age was 38 years and most patients were white (84%). Patients had an average of 5.5 migraine episodes per 30 days and 8.5 migraine days per month.
The patients were randomized to one of four treatment groups. Triptan dose and route of administration were adjusted to achieve optimal acute therapy. Use of antiemetic and rescue medications was adjusted for optimal effect. The primary preventive medication was propranolol-LA (up to 240 mg/day). However, if the drug was ineffective or intolerable, nadolol (up to 120 mg/day) was used. OAT and preventive medication doses were adjusted over a 4-month period to optimize efficacy. During this period, patients had monthly clinic visits and received two phone calls from study staff.
For behavioral migraine management, patients were taught a variety of skills that have been shown to be effective. Patients learned about identifying warning signs and triggers, effective use of medication, reducing the impact of migraine, and biofeedback. Instruction involved clinic visits, telephone calls, home workbooks, and audio tapes.
All patients had five clinic visits (baseline and four monthly visits), which primarily involved medication monitoring, dose adjustment, and quality of life assessment. Quality of life was assessed using the Headache Disability Inventory and the Migraine-Specific Quality of Life Questionnaire. Migraine activity and medication compliance were evaluated using a computer-based diary.
In terms of migraine activity, 80% of those who used both preventive medication and behavioral migraine management along with OAT had at least a 50% improvement in both episodes per month and migraine days per month. OAT alone, OAT with preventive medication, and OAT with behavioral management resulted in less than half of patients experiencing at least a 50% reduction in migraine activity. Looking at quality of life, both the OAT/preventive medication approach and the OAT/behavioral management approach produced improvements over OAT alone.
It is hypothesized that migraines tend to occur in clusters because there is progressive sensitization during the course of a migraine that can persist for up to 96 hours, leaving the sufferer vulnerable to subsequent episodes.
“It's possible that if you completely abort the first migraine before it becomes severe, subsequent migraine clusters won't occur,” Dr. Holroyd said.