Optimizing prophylactic treatment of migraine: Subtypes and patient matching

Abstract

Advances in our understanding of the pathophysiology of migraine have resulted in important breakthroughs in treatment. For example, understanding of the role of serotonin in the cerebrovascular circulation has led to the development of triptans for the acute relief of migraine headaches, and the identification of cortical spreading depression as an early central event associated wih migraine has brought renewed interest in antiepileptic drugs for migraine prophylaxis. However, migraine still remains inadequately treated. Indeed, it is apparent that migraine is not a single disease but rather a syndrome that can manifest itself in a variety of pathological conditions. The consequences of this may be that treatment needs to be matched to particular patients. Clinical research needs to be devoted to identifying which sort of patients benefit best from which treatments, particularly in the field of prophylaxis. We propose four patterns of precipitating factors (adrenergic, serotoninergic, menstrual, and muscular) which may be used to structure migraine prophylaxis. Finally, little is known about long-term outcome in treated migraine. It is possible that appropriate early prophylaxis may modify the long-term course of the disease and avoid late complications.

Keywords: diagnosis; migraine; prophylaxis; subtypes; treatment.

Figure 1

Potential long-term course of migraine headaches.

Figure 2

A classification of migraine headaches based on triggering factors.

Figure 3

Relief of migraine attack in 235 patients included in a comparative study of ketoprofen and zolmitriptan using a cross-over design (Dib et al 2002). Data are given as the percentage of the total number of attacks that were reduced in severity to mild or absent at two hours. Treatment groups are placebo (P), ketoprofen 75 mg (K75), ketoprofen 150 mg (K) and zolmitriptan 2.5 mg (Z). The asterisk indicates a significant difference (p < 0.0001; GEE model) between the bracketed groups.

Figure 4

Treatment hierarchy for the acute treatment of migraine with triptans.

Figure 5

Efficacy of topiramate in the prophylaxis of migraine. Three different doses of topiramate (TPM; 50 mg/day, 100 mg/day, and 200 mg/day) are compared with placebo (Pbo). Data represent the change in monthly migraine frequency compared to a pre-treatment baseline period. The asterisks indicate a statistically significant difference from placebo (*p < 0.01; **p < 001). Data are taken from Brandes and colleagues (2004) (grey columns) and Silberstein and colleagues (2004) (black columns).