How Doctors Determine Acute Migraine Treatment Plans: Q&A with Stewart Tepper, MD, FAHS

Dr. Tepper walks through what needs to be considered when determining how to treat a patient’s migraine attacks

Patients with migraine are all different individuals, and this needs to be reflected in their treatment plans. AHS board member Stewart Tepper, MD, FAHS, professor of neurology at the Geisel School of Medicine at Dartmouth and the director of the Dartmouth Headache Center at Dartmouth Hitchcock Medical Center in the Department of Neurology, recently spoke with us about how to determine the best way forward.

What details of a patient’s medical history should a headache specialist consider when creating an acute migraine treatment plan?

There are a number of considerations that we have to take into account right from the beginning. The first thing I ask about is how quickly a patient’s attacks get bad. We also want to ask about is how many of the migraine attacks are in the morning, as well as how many of the attacks are already full-blown when a patient is going to be reaching for treatment.

The next set of questions are about the associated features such as nausea. We ask patients if they get nauseated during an attack, as well as when and how badly. Nausea can interfere with a pill working, and the presence of vomiting means a pill may not be a reasonable option most of the time—or that the patient needs an anti-nausea medicine in addition to their migraine treatment. We also have to decide, depending on the frequency and severity of attacks and associated disability, whether this person needs preventive treatment to lower the number of headache days, which can then help the acute treatment work.

All of this really has to be evaluated at the first visit. Once these answers are lined up, decisions can be made about therapy.

As a headache specialist, what do you do when a patient’s acute migraine treatment plan isn’t working?

Providers need to know why and how a treatment is not working. I used to make the same mistake everybody often makes—somebody would tell me a drug doesn’t work, and I would suggest we try another. That’s really not the way that answer should be handled, because there are a variety of reasons that a drug might not meet a patient’s expectations. The medication might be too slow or it might not get a patient pain-free at two hours; it might not be consistent enough across attacks so that a patient can really count on it.

Healthcare providers must be willing to listen to how the treatment is not matching the attack characteristics of a person across time. Not all attacks are the same, so there are a lot of important questions to ask when somebody comes in and says, “It’s not working.” If somebody says a treatment is not working and you explore it a little bit with them, you can find out why it’s not working and make some adjustments.

Is there ever a situation when a patient says a particular treatment isn’t working and the headache specialist would encourage them to stick with it for a little longer?

One example where I might persist is if somebody’s only tried a treatment once. For example, with triptans, people who don’t get a response the first time will sometimes get a response the second or third time. I always ask my patients to try it during at least three different attacks—not to try it and then try it the next day during the same headache. That doesn’t really count.

Acute treatments also tend to work better when taken early. I always tell people that I want them to take the triptan when they say to themselves that “This is not really a migraine.” People always say, “It’s not really a migraine this time, I am going to get away with this over-the-counter medicine, or with eating or having a nap.” But it generally doesn’t work that way. You have to be vigilant and treat early with triptans, then there is a greater opportunity to get a sustained pain-free response.

Stewart Tepper, MD, FAHS, is a member of theAmerican Headache Society, a professional society for doctors and other healthcare workers who specialize in studying and treating headache and migraine. The Society’s objectives are to promote the exchange of information and ideas concerning the causes and treatments of headache and related painful disorders, and to share and advance the work of its members. Learn more about the American Headache Society’s work and find out how you canbecome a member today.