Assessment of Illness Severity

Migraine is a disabling condition and attacks differ in severity in individual patients, and even in attacks experienced by each sufferer, in terms of frequency, duration, symptomatology and associated disability.^[2] No single feature is predictive of migraine severity, and it is recommended that the following features should be assessed by the physician:

• Attack frequency and duration

• Pain severity

• Impact

• Non-headache symptoms

• Individual patient factors, such as their history, treatment preferences and other illnesses.^[15,16]

Two questionnaires have been developed to assess the impact that migraine (and headache in general) has on the sufferer's lifestyle: the Migraine Disability Assessment (MIDAS) Questionnaire, which assesses the disability caused by the headache^[32]; and the Headache Impact Test (HIT), which assesses impact as a composite measure of several assessments.^[33,34]

The MIDAS Questionnaire. MIDAS is a paper-based questionnaire, designed to be accessible at physicians' surgeries and pharmacies (information available at www.migraine-disability.net). Migraine sufferers answer five disability questions in three activity domains covering the previous 3-month period (Figure 5). They score the number of lost days due to headache in employment, household work and family and social activities. Sufferers also report the number of additional days with significant limitations to activity (defined as at least 50% reduced productivity) in the employment and household work domains. The total MIDAS score is obtained by summing the answers to the five questions as lost days due to headache. This can sometimes be higher than the actual number of lost headache days due to any one day being counted in more than one domain. The score is categorised into four severity grades:

• Grade I = 0-5 (defined as minimal or infrequent disability)

• Grade II = 6-10 (mild or infrequent disability)

• Grade III = 11-20 (moderate disability)

• Grade IV = 21 and over (severe disability)^[32]

Figure 5. (click image to zoom) The Migraine Disability Assessment (MIDAS) Questionnaire. The MIDAS Programme was developed by Innovative Medical Research Inc, with sponsorship and assistance from AstraZeneca[32]

Figure 6. (click image to zoom) The Headache Impact Test (HIT-6TM) Questionnaire. HIT was developed by QualityMetric Inc and GlaxoSmithKline[34]

Both MIDAS and HIT have been tested extensively and shown to be reliable and valid, with wide potential for clinical utility.^[35] They can be used to:

In addition, MIDAS is sensitive to change and can be used to provide an outcome measure to monitor the success of interventions.^[36,37] HIT, unlike MIDAS, can be used as a diagnostic tool to differentiate between headache subtypes.^[38] Both questionnaires can be recommended to primary care physicians as aids to the management of migraine and other headaches.^[35]

Provision of an Individualised Management Plan: Evidence-Based Recommendations for Therapy

Management of migraine needs to be individualised for each patient due to the heterogeneity of migraine attacks,^[2] the different needs of each patient's lifestyle and the wide variety of available therapies, both pharmacological and non-pharmacological. These include behavioural therapies, acute therapies, prophylactic therapies and complementary medications. Recently, the first evidence-based recommendations for migraine therapies were published, based on the Duke database.^[15,39,40] The clinical data on each migraine therapy was rated in the order: data from large, randomised, placebo- or comparator-controlled clinical trials and/or meta-analyses rated superior to data from less rigorously conducted clinical studies rated in turn superior to the consensus of a group of physicians.

Behavioural and Physical Therapies. It has been recommended that behavioural therapies should be provided for all migraine sufferers to help prevent the development of attacks (Table 3).^[40] Several studies support the use of biofeedback to prevent migraine attacks, and relaxation therapy may be equally as effective, with improvements of 30-40% in headache index reported.^[40] However, there seems to be no additive effects of combining the two therapies. Additional efficacy was sometimes reported when the behavioural therapy was combined with prophylactic drugs.^[40] The avoidance of migraine trigger factors has been suggested to be effective, but evidence is equivocal. About 20% of patients can reduce the frequency of their migraine attacks by identifying specific migraine triggers and avoiding them.^[41] Several studies have shown that stress reduction is an effective strategy to reduce the frequency and impact of migraine. There was a reduction in the number of attacks of approximately 50% and the effect was moderately large.^[40] Avoiding red wine is also a plausible strategy, but as yet there is little evidence for the avoidance of other foods.^[40] MIPCA is currently conducting an audit that investigates the possible role of food intolerances in migraine.

Several physical therapies have also been tested for migraine. Studies have shown that cervical manipulation, massage and exercise may provide additional adjunctive therapy if used with other stress reduction strategies.^[40] However, there is not enough evidence to allow the recommendation of hypnosis, transcutaneous electrical nerve stimulation (TENS), occlusal adjustment and hyperbaric oxygen.^[40]

Acute Therapies. The goals of acute therapy should be to rapidly and effectively relieve the pain and non-headache migraine symptoms, allowing a resumption of the patient's normal activities.^[15] Acute therapies should not be over-used, to avoid the complications of analgesic overuse. Many physicians have advocated that acute medications be taken regularly on < 2 days per week,^[21] although this may be different in practice if patients have attacks lasting for several days that require effective treatment over this length of time.

It is generally recommended that acute therapies be provided for all patients, as breakthrough attacks inevitably occur when preventative therapies fail.^[21] Most patients with infrequent attacks will only require acute therapy. Rescue therapy is also recommended if the first-line therapy is ineffective.^[15] Studies to evaluate acute treatments for migraine are now undertaken to rigorous methodological standards and procedures so as to allow the objective evaluation of results and the comparison of different medications.^[42]

Acute migraine therapies have not always been chosen systematically in the past, and often a trial and error system has been used. One of three types of treatment strategy is typically used; step-care, staged care and stratified care (Figure 7).^[16,18]

• In step-care, patients initiate treatment with one medication (usually a simple analgesic) for a series of attacks. If this treatment fails, the physician can step the patient up to alternative, stronger medications for subsequent attacks. This stepping process continues until an effective medication is found or the patient lapses from care.

• Staged care is a variant of step-care, where patients initiate treatment for each attack with a simple analgesic. If this treatment fails, they can take stronger medications as rescue therapy.

• In stratified care, the physician grades each patient as to the impact the migraine has on their lifestyle. This can be done using detailed history taking, or by using the MIDAS or HIT questionnaires.^[43] The physician then prescribes therapy appropriate to the severity of the migraine. Patients suffering from little or no impact can be given simple analgesics or combination medications, while those with significant impact may be provided with migraine-specific therapies from the outset.

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