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Management of Migraine: The Challenges We Face and How to Meet Them

In addressing what I perceive to be the major challenges we face in managing migraine and how those challenges might be met, I will invoke two of the very few areas where my own personal knowledge may exceed that of the typical headache subspecialist: stroke and the American Civil War (or, as fondly referred to throughout Deepest Dixie, “the War of Northern Aggression”). The linkage with stroke is not so far-fetched as it may seem at first glance. In headache medicine there is a rich tradition of stroke/headache “hybrids”: Welch, Ramadan, Aurora, Tietjen, Gordon, Bousser, Kurth, Diener, and Rothrock . . . to name a few. Furthermore, at least within my 30 years of experience, the two fields share something of a common history. What was the “state of stroke” in 1983, the year when I was recruited to the University of California, San Diego to develop a stroke center? Stroke was .. (1) undeniably a major public health burden; (2) poorly understood in terms of its pathophysiology; (3) managed primarily by diagnostic testing and rehabilitation; and (4) practically devoid of any evidencebased treatment. Circa 2012 stroke remains a major public health burden (and, in fact, its incidence continues to increase). Stroke is far better understood in terms of its pathophysiology. It is managed in a far more coherent fashion, from primary prevention to acute intervention, early rehabilitation, and, ultimately, secondary prevention. Finally, stroke incidence and outcome may be modified via a (modest) number of evidence-based therapies. What was the status of migraine circa 1983? (1) It represented a major public health burden; (2) its pathophysiology was poorly understood; (3) in terms of management, identification of migraine was hampered by imprecise, subjective, and nonspecific diagnostic criteria; and (4) its treatment was notable for the near-total absence of any therapies that currently would qualify as being evidence based. And what about migraine, circa 2012? The disorder definitely remains a major public health burden, and its incidence appears to be increasing. We have a far better understanding of migraine’s biogenesis and pathophysiology. Diagnostic management has improved consequent to the widespread adoption of more precise and objective criteria. Best of all – especially from our patients’ perspective – we have on hand a (barely) respectable handful of evidencebased treatments. Looking at the second and fourth of these (i.e., biogenesis/pathophysiology and treatment) and attempting to assign a letter grade for our progress over the past 29 years, I would award a “B” to our efforts in the area of biogenesis/pathophysiology and a “D+” for therapy. As for the specific therapies that have enabled us to avoid a failing grade, I would list (in chronological order) subcutaneously administered sumatriptran, divalproex sodium, topiramate, and onabotulinumtoxinA. While many will excoriate me for the conspicuous absence of the oral triptans from this list, I can only reply that – in my estimation From University of Alabama School of Medicine, 3401 Medical Park Drive, Building 3, Suite 205, Birmingham, AL 36693, USA, email: jrothroc@uab.edu ISSN 0017-8748 doi: 10.1111/j.1526-4610.2012.02127.x Published by Wiley Periodicals, Inc. Headache © 2012 American Headache Society