I will be speaking on nutritional supplements for migraines and an update on triptans on April 20, 2024.

A recent national survey called the “Harris Poll Migraine Report Card” provides insight into the profound impact migraine has on people’s lives, especially those dealing with frequent attacks and high acute medication use. The survey compared those currently experiencing high-frequency migraine (8 or more attack days per month) and using acute medication on 10 or more days per month, to those who previously had this pattern but now have reduced attack frequency and medication use.

Most respondents were first diagnosed with migraine or headache disorders in their mid-20s. However, despite meeting criteria for migraine, one-third did not self-identify as having migraine disease. This underscores how migraine is still underrecognized and misdiagnosed, with people often being mislabeled with terms like “stress headache.”

Regardless of diagnosis, the burden was clear – over 50% reported a negative impact on their overall quality of life. What’s more, at least half had experienced anxiety or depression, with almost half to over half saying migraine negatively affected their mental/emotional health. These findings align with prior research showing a significant burden can start at just 4 monthly migraine days.

In an attempt to improve their condition, most made lifestyle changes like stress management, limiting caffeine and improving diet. However, their treatment choices differed – those with more frequent migraine were more likely to use newer acute treatments like gepants, diclofenac and dihydroergotamine compared to the other group using more NSAIDs, triptans and ergotamines. The high-frequency group was also more inclined to try non-pharmacological options like supplements, marijuana, massage and physical therapy.

The use of prophylactic medications was low in both groups – about 15%. There are several potential reasons including lack of access to neurologists or even primary care doctors, lack of efficacy and side effects of existing drugs, and clinicians not encouraging the use of preventive medications.

The difference between these two groups could at least in part relate to the older age of the previous high-frequency group (mean age, 47 years vs 41), as age-related improvement can occur over time.

Interestingly, the high-frequency group had poorer optimization of their current acute treatments compared to those who previously experienced high frequency but reduced their attack frequency.

This brings the controversial issue of acute medication overuse into focus – does the suboptimal acute treatment lead to frequent use of medications, rather than the current widely accepted dogma that postulates that frequent use leads to more frequent headaches?

There is evidence that caffeine and opioid analgesics make headaches worse. The evidence for triptans and NSAIDs is based purely on correlational studies. Yes, I occasionally see patients improve when they stop or reduce their intake of NSAIDs or triptans. More often improvement comes from instituting effective preventive therapies along with lifestyle changes. NSAIDs have been proven to be effective for the prevention of migraine attacks and I have dozens of patients whose migraines are well-controlled with daily prophylactic or acute use of triptans. The safety of triptans is greater than that of NSAIDs and most prophylactic medications such as antidepressants and epilepsy drugs.

The concept of acute medication “overuse” may be unhelpful and stigmatizing, as it suggests frequent attacks are the patient’s fault rather than a disease manifestation. Optimizing acute treatments may naturally reduce the need for frequent medication use as attacks improve.