Migraine Clinical Guidelines and Treatment
In the absence of a cure for migraine, the aims of migraine management at primary care level are:
- The successful treatment of the migraineur’s acute attack
- The prevention and limitation of future attacks
- To encourage migraine sufferers to continue with their care
- The identification and referral of the minority of patients who need specialist services
The Stratified Care approach
The Stratified Care approach is the approach of choice when treating headache disorders, whereby the doctor decides what treatment is necessary based on the evidence for that treatment and the individual patient’s needs. Recent best practice guidelines on the management of migraine such as the Migraine in Primary Care Advisors (MIPCA) guidelines from the UK, the US Headache Consortium, and the Primary Care Network guidelines are based on the Stratified Care model.
‘Stratified Care’ has now largely superceded the ‘stepped care’ approach which began with analgesics (perhaps with an anti-emetic) for all patients regardless of headache impact, severity or frequency, and if those are not effective, the patient is “stepped up” to the next level of treatment, reserving the more powerful triptans as third-line options.
Under a stratified approach:
- Each patient should have an individual treatment plan, based on factors such as headache frequency, duration and severity, non-headache symptoms, the impact it has on the patient’s life and the patient’s own history and preference.
- Migraine specific treatments should be provided from the start if necessary. Rescue medication is recommended in case the initial therapy fails.
The MIDAS and Headache Impact Test (HIT) tests can be useful for helping the doctor implement a stratified treatment plan.