Migraine
Summary
For people with migraine, today’s world is a better world than the one their parents knew. The last 15 years have seen major advances, giving us not only a much clearer understanding of the disorder but also considerably more effective therapies. Treatments exist that – if made available and used in the right way – can substantially relieve the majority of people affected by migraine.For people with migraine, today’s world is a better world than the one their parents knew. The last 15 years have seen major advances, giving us not only a much clearer understanding of the disorder but also considerably more effective therapies. Treatments exist that – if made available and used in the right way – can substantially relieve the majority of people affected by migraine.
Availability and correct usage are key issues. Management guidelines for migraine are not uniform throughout the world, though all recommend the objective of the best possible control of symptoms, reducing their impact on life and lifestyle to the bare minimum. Of course, this means treatment should be individualised. Since clear criteria do not exist for matching treatments to patients, it also means that patients should try the treatment options in some rational order until they are certain they have found what suits them best. Stopping short of this is suboptimal management.
The options for an acute attack (and there are further choices within each option) are symptomatic medications (i.e. analgesics with or without antiemetics) or specific antimigraine drugs (i.e. the triptans). Prophylaxis can then be added to the treatment regimen to reduce the number of attacks only when optimised acute therapy gives inadequate attack control or when reliance upon acute therapy alone leads to its over-frequent use.
There are major cost differences between the acute treatment options and these differences lead to contrasting views over what is the most logical order in which to try them. Cost may not be ignored in times of healthcare resource limitation, and therefore it appears that triptans should not be used if much cheaper symptomatic medications do just as well. On the other hand it defeats the stated objective of management to withhold triptans from those who need them. A systematic approach is therefore required that achieves these outcomes.
Such an approach should bring success for most patients, measured from their own subjective viewpoints. Problem solved. The public-health perspective, however, tells a very different story. Migraine is common throughout the world, is most prevalent during the productive years (late teens to the 50s) and also disables most of those affected by it. The consequential losses in work time and productivity give rise to massive indirect costs and thus a huge socioeconomic burden.1,2 Substantial investment in its treatment might be expected, at least in developed countries. Whilst the World Health Organization has recognised migraine quite clearly as a disorder with global public health importance, the reality is that few, if any, national governments have it anywhere on their list of priorities.3,4 Direct treatment costs are in comparison quite low. In other words, healthcare systems worldwide spend a small fraction of the total cost of migraine on measures to alleviate it, and the consequence is that migraine remains under-diagnosed and under-treated across the globe. The overall result is that the ‘better world’ is perceived only by a minority: the benefits of effective management reach only a few and, to the rest, access is denied.
This is a major challenge. One main component of our response should lie in education and raising awareness of the issues, which is necessary from governments down and from the general public up. The first barrier to access to care is that many people with migraine do not seek help, for reasons that are complex but largely negative, and based primarily upon low expectations of the care that they will receive. The other main component of the response is to recognise that, since no elements of good migraine management demand special facilities, its management should be centred in primary care – delivered locally with ease of follow-up, which is absolutely crucial to getting it right. That is not to say that good migraine management does not demand special clinical skill, because it most certainly does, but primary-care physicians are as able as any specialist to develop this given the number of cases they will see. Migraine management would also benefit from genuine professional interest in the disorder, which may be where deficiencies currently occur both in general practice and in neurology clinics.
References
1 Fishman P, Black L. Indirect costs of migraine in a managed care population. Cephalalgia 1999; –7.
2 Steiner TJ, Scher AI, Stewart WF, Kolodner K, Liberman J, Lipton RB. The prevalence and disability burden of adult migraine in and their relationships to age, gender and ethnicity. Cephalalgia 2003; 23: 519–27.
3 World Health Organization. Headache disorders and public health. Education and management implications. : WHO, 2000.
4 World Health Organization. The World Health Report 2001. : WHO, 2001.
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This Editorial has been written by the specialist opinion leader, Dr Timothy Steiner,
, and published in the latest issue of the serial publication, Drugs in Context.
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