Pharmacy & Therapeutics- August 2008 - (Page 484) CONTINUING EDUCATION CREDIT treatment choices are based on the severity of the headache. The Disability in Strategies of Care (DISC) Study provided evidence that using a stratified-care approach might be able to improve headache response and disability time. In this multicenter study, which was conducted in 13 countries, the Migraine Disability Assessment Scale (MIDAS) was used to compare the stratified-care and stepped-care approaches.166 Patients receiving stratified care were treated according to their MIDAS scores and initially received either aspirin plus metoclopramide (Reglan, Schwarz) or zolmitriptan (Zomig). For the stepped-care group, initial attacks were treated with aspirin and metoclopramide; patients could use a stepped-care strategy during an attack and zolmitriptan therapy with set parameters. Even though the study suggested that the stratified-care approach resulted in improved clinical outcomes, the study’s limitations included an open-label design, a small number of pharmacotherapies, different methods of selecting therapies for the stratified group, and concerns about whether rapid escalation of therapy was comparable to that in clinical practice. Investigators conducting future trials of stratification might consider other factors, such as symptom profiles, genetics, and biological markers.166 The present guidelines suggest the use of simple analgesics or NSAIDs for aborting mild-to-moderate migraine and the triptans or possibly the ergots for aborting moderate-to-severe migraines. Considerations for preventive therapy are usually based on the frequency and severity of migraine and other comorbidities, and these approaches may include beta blockers, TCAs, and anticonvulsants.1,163–165 2. Matchar DB, Young WB, Rosenberg JH, et al. Evidence-based guidelines for migraine headache in the primary care setting: Pharmacological management of acute attacks. Available at: www. aan.com/public/practiceguidelines/03.pdf/. Accessed August 2007. 3. Diamond S, Bigal ME, Silberstein S. Patterns of diagnosis and acute and preventive treatment for migraine in the United States: Results from the American Migraine Prevalence and Prevention study. Headache 2007;47(3):355–363. 4. Ramadan NM, Silberstein SD, Freitag FG, et al. Evidence-based guidelines for migraine headache in the primary care setting: Pharmacological management for prevention of migraine. U.S. Headache Consortium. Available at: www/aan.com/professional/ practice. Accessed August 2007. 5. McCory DC, Matchar DB, Rosenberg JH, et al. Evidence-based guidelines for migraine headache: Overview of program description and methodology. Available at: www.aan.com/public/practiceguidelines/03.pdf. Accessed August 2007. 6. Bekes M, Matos L, Rausch J, et al. 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Comparative efficacy of nadolol and propranolol in the management of migraine. Headache 1987;27:421–426. 21. Olerud B, Gustavsson CL, Furberg B. Nadolol and propranolol in migraine management. Headache 1986;26:490–493. 22. Gallagher MR, Stagliano RA, Sporazza C. Timolol maleate, a beta blocker, in the treatment of common migraine headache. Headache 1987;27:84–86. 23. Steiner TJ, Hedman C, Rose FC. Metoprolol in the prophylaxis of migraine: Parallel-group comparison with placebo and dose-ranging follow-up. Headache 1987;28:15–23. 24. Johannsson V, Nilsson LR, Widelius T, et al. Atenolol in migraine prophylaxis: A double-blind cross-over multicentre study. Headache 1987;27:372–374. 25. Forssman B, Lindblad CJ, Zbornikova V. Atenolol for migraine prophylaxis. Headache 1983;23:188–190. 26. Worz R, Reinhardt-Benmalek B, Grotemeyer K-H, et al. Bisoprolol and metoprolol in the prophylactic treatment of migraine with and without aura: Randomized double-blind cross-over multicenter study. Cephalalgia 1991;11(Suppl 11):152–153. 27. van de Ven LLM, Franke CL, Koehler PJ. Prophylactic treatment Conclusion The pharmacotherapy of migraine is complex. The appropriate use of preventative medications requires an understanding of the various agents available and when they are best used. Part 1, in the July 2008 issue of P&T, reviewed the abortive pharmacotherapy for migraine, the role of these agents, and especially their frequency, which affects the use of preventative therapy. The management of migraine requires a multidisciplinary approach and calls for physicians experienced in headache management along with nurses, social workers, and pharmacists. The large number of patients experiencing migraine results in significant medication usage and the potential for drugrelated problems. Although all health care professionals constitute an important part of the care of the migraine patient, pharmacists can also play a major role by monitoring medication usage, evaluating patients’ responses to therapy, and assessing adverse effects and drug interactions. Pharmacists should also play a prominent part in educating patients about their medications and in providing information on appropriate use. References 1. Silberstein SD, for the U.S. Headache Consor tium. Practice Parameter: Evidence-Based Guidelines for Migraine Headache (An Evidence-Based Review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000; 55:754–762. 484 P&T® • August 2008 • Vol. 33 No. 8 http://www.aan.com/public/practiceguidelines/03.pdf/ http://www.aan.com/public/practiceguidelines/03.pdf/ http://www.aan.com/public/practiceguidelines/03.pdf http://www.aan.com/public/practiceguidelines/03.pdf
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