Over the past 5 years, initiatives have led to the development of new guidelines for migraine management in the UK and the USA: the UK MIPCA guidelines,^[12] the US Headache Consortium Guidelines,^[15,16] and the US Primary Care Network Guidelines.^[17]

The UK MIPCA Guidelines

MIPCA guidelines were first issued in 1997, and revised guidelines were published in 200012. MIPCA advocates an individualised approach to care, treatment being prescribed according to each patient's needs. Factors considered include the nature of the patient's attacks, the impact of headache on the individual's life and the demands of the patient's lifestyle (Figure 1).

At the initial consultation, the physician is recommended to conduct a diagnostic assessment and to take a careful history covering the nature of the headaches, previous treatments taken and the impact on the patient's life. Patients who experience up to four attacks per month are given acute therapy with a simple analgesic (with or without an anti-emetic) or an oral triptan if analgesics have been used unsuccessfully in the past. Nasal spray or subcutaneous triptan formulations may be considered if the patient has difficulties with oral therapies or requires a fast therapeutic effect due to the demands of their lifestyle or presentation characteristics of their headaches. It is deemed essential to establish a goal for therapeutic intervention. Useful goals centre on preservation of function or being free of pain and associated migraine symptoms. In our experience, merely providing enough relief to 'get through' an attack commonly results in the patients lapsing from care.

If the initial therapy is unsuccessful, an alternative triptan may be provided. For patients who fail on this therapy, and for migraine patients with four or more headaches per month, prophylactic treatment is recommended with additional acute treatment for breakthrough attacks. Migraine patients who fail on this treatment, and those diagnosed with chronic daily headache, may require referral to a specialist physician.

The US Headache Consortium Guidelines

New practice guidelines for the management of migraine were published by the US Headache Consortium in 2000.^[15] Identified goals of successful migraine management were reduction of attack frequency, severity and disability, improvement of QOL, prevention of headache, avoidance of the escalation of acute medications and the education of patients to better self-manage their illness.

The US Headache Consortium identified several principles of managing migraine (Figure 2). Following a diagnostic assessment, the physician is recommended to assess the illness severity, by taking a history of attack frequency and severity, degree of disability, the presence of non-headache symptoms and patient-specific factors such as their prior response to medications and co-existent conditions. A major part of these guidelines is the education of patients about their condition and its treatment, to establish realistic expectations and to encourage them to participate in the management of their migraine. Finally, an individualised treatment plan is advocated, tailoring therapy to the patient's symptoms, illness severity, disability and personal needs.

The US Headache Consortium mostly used evidence-based medicine (based on a database produced by Duke University, North Carolina, USA) to rate different treatments, but where this was not possible due to lack of data, a consensus was reached. They recommend a stratified approach to care, whereby the initial prescribed therapy is based on a baseline assessment of the illness severity and treatment needs of the patient.^[18] NSAIDs and combinations of analgesics with anti-emetics are recommended for patients with mild-to-moderate migraine. Migraine-specific agents (e.g. triptans) are recommended for patients with moderate-to-severe migraine and for those who have previously failed on the NSAIDs and combination analgesics.^[15] The consortium advocates a non-oral route of administration for patients with severe nausea and vomiting and a rescue medication for treatment failures. Finally, physicians are cautioned to guard against the overuse of headache medications.

The US Primary Care Network Guidelines

The Primary Care Network is a group of physicians working in private practice, managed care and academia, who provide medical programmes for the management of diseases in US primary care. The Primary Care Network advocates the impact-based recognition of migraine and acute and preventative treatment strategies, together with special guidelines for using behavioural and physical treatments, treating chronic headache disorders and specific patient groups (Figure 3).^[17]

Impact-based recognition of migraine involves the physician eliciting information on how headaches interfere with the patient's life, the frequency of headaches, any changes in headache pattern over the preceding 6 months and the previous use and effectiveness of headache medications. The guidelines for acute treatment are to abort migraine symptoms and disability within 2-4 hours of initiating therapy. Key tactics for achieving this are identified as providing patient education and instruction and tailoring intervention to the individual's needs. The Primary Care Network recommends treating migraine early in the attack when the headache is mild with triptans, NSAIDs, isometheptene (Midrid^® in the UK) or combination analgesics. Migraine-specific treatments such as triptans are recommended if the headaches are likely to become moderate or severe. In practice, this includes most migraine patients, as nearly 85% of patients with significant impact associated with their migraines have attacks that routinely become moderate-to-severe.^[19] This follows recent clinical trial evidence that early intervention with triptans when the migraine headache is mild is the most effective treatment option for migraine.^[20] Preventative treatment is designed to reduce attack frequency, duration, severity and disability, and prevent the development of chronic daily headache in patients with frequent headaches. Again, this involves patient education and instruction, plus the development of a formal management plan.

http://www.medscape.com/viewarticle/446557_2