Emerging Treatment for Migraine - Episode 5

Concerns Surrounding Migraine Medication Misuse

Peter L. Salgo, MD: Let’s talk about folks who are self-medicating. In other words, they’re not going to go to the doctor every time they’ve got a migraine. Is there a process for monitoring the use of these drugs or the misuse of these drugs?

Malaika Stoll, MD, MPA: That’s what you want—for them to self-medicate. You want them to take it when the pain comes on. You certainly don’t want them to have to see the doctor or go to the emergency department every time this happens. This is a big cause of emergency department visits. We want folks to have this very helpful medication on their shelves.

Peter L. Salgo, MD: As a patient advocate, you need to explain the protocol for managing a disease at home to the people who have migraine and their caregivers. As with diabetes, we have to make decisions on the fly and take charge of our own health.

Peter Goadsby, MD, PhD: When you look at emergency departments, they’re bright, noisy, and smelly.

Peter L. Salgo, MD: I think we’ve all been in emergency departments. They’re just not migraine friendly.

Peter Goadsby, MD, PhD: Exactly. Patients are sensitive to light. They’re sensitive to sound. They’re sensitive to smells. They’re sensitive to moving them about. Emergency departments are just about the worst place in the world to send a migraine patient, unless you want to torture them.

Jill Dehlin, RN: I tell people to avoid going to the emergency department and to have a plan in place with your physician. If you inevitably do have to go to the emergency department, bring something with you that the physician has written out—a protocol that they can use in the emergency department. Unfortunately, not all emergency department physicians are experts in migraine and its treatment.

Peter L. Salgo, MD: That’s why we’re doing this today. Is there a concern that patients are just gobbling up over-the-counter medications on their own and that they are not really getting the help that they need and can get if they were more integrated?

Jill Dehlin, RN: When I found out what the discussion points were on Monday, I did a quick survey using social media. I had 140 responders in 48 hours, which I think is pretty good. Thank you, everyone. Most people are worried about medication overuse. They’re very cognizant of monitoring the use of their medications and keeping track of how many they use.

Peter L. Salgo, MD: Because they’re worried about overuse, does that mean that they’re undermedicating and suffering unnecessarily?

Jill Dehlin, RN: It does.

Peter Goadsby, MD, PhD: It’s a complex thing because a person has to function. They’ve got their life. They need to get to the studio and have a chat. So at one level, we’ll tell them not to take something when they’re in a difficult situation. It’s difficult. At the other level, we know that doing that will make a headache worse in a proportion of people. We know that the overuse rates in the United States are nudging about 1% of the entire population.

Peter L. Salgo, MD: OK.

Peter Goadsby, MD, PhD: That’s a lot of people.

Malaika Stoll, MD, MPA: I think it’s helpful, however, at least for migraines, that compared with some other conditions, the medications that are very effective are not the medications that folks tend to abuse, like the opiates. Those are fourth-line, fifth-line options. Those are not what we would necessarily give right away for migraines. Those have a lot of abuse potential, and we keep our eyes on those.

Peter Goadsby, MD, PhD: Triptans have the potential for medication overuse. There are very good data in the United States population that demonstrate that if you take triptans for 12 days or more per month, you’re at increased risk for having more headaches in the following 12 months. Nothing that we have, at the moment, is as clean as the driven snow when it comes to medication overuse.

Peter L. Salgo, MD: What is our biggest concern here? Is it medication overuse among patients, or is it underutilization of medication by patients?

Peter Goadsby, MD, PhD: I think the biggest problem is undermanagement. If you need to take an acute medication more than once a week, you need to have a discussion about prevention. We’re talking about when people are already well out of hand. That needs to be gotten a hold of much earlier. The message to doctors and patients has to be that once the number of attacks is starting to escalate, that’s the time to talk about prevention.

Peter L. Salgo, MD: Let’s talk about guidelines. Everybody has guidelines for everything. My desk is this high in guidelines that I’ll never get to. Tell me about the most recent American Academy of Neurology and American Headache Society clinical guidelines for migraine.

Peter Goadsby, MD, PhD: The most recent guidelines from the American Academy of Neurology and American Headache Society date back to around the triptan era. We are, as a society, revising them at the moment, as the new therapies are coming out. The guidelines will tell you that, for example, triptan use needs to be limited. We use a recommendation of less than 10 dose days per month to try to avoid this medication overuse problem for acute therapies. We’re not very keen on opioids, as has already been said, because of the potential for medication overuse problems and the potential for addiction and abuse problems.

Peter L. Salgo, MD: I had heard that opioids don’t work very well anyway.

Peter Goadsby, MD, PhD: No, they don’t work very well.

Peter L. Salgo, MD: So it’s a triple play, if you will.

Peter Goadsby, MD, PhD: If you compare opioids to much simpler therapies, they actually underperform in randomized controlled trials.

Jill Dehlin, RN: It can precipitate going into chronicity.

Peter L. Salgo, MD: I don’t even want to discuss what someone withdrawing from opioids with migraine must feel like.

Jill Dehlin, RN: It’s terrible.

Peter L. Salgo, MD: Let’s avoid this altogether.