New US guideline recommends combination therapy for acute episodic migraines

The American College of Physicians (ACP) has developed new recommendations for treatment of acute episodic migraines in non-pregnant adults in outpatient settings.

The new guideline, Pharmacologic Treatments for Acute Episodic Migraine Headache in Outpatient Settings: A Clinical Guideline from the American College of Physicians was published earlier this year in the Annals of Internal Medicine.

Migraine is characterised by recurrent episodes of usually moderate-to-severe intensity headache lasting four-to-72 hours with or without sensory disturbances, generally pulsating and often accompanied by nausea, vomiting, or aversion to light or sound. The condition remains underdiagnosed and undertreated.

ACP evaluated pharmacologic treatments known to be effective for migraine treatment using the best available comparative effectiveness evidence of benefits and harms, patients’ values and preferences, and economic evidence in order to prioritise the most effective treatments.

In its guideline, ACP makes two recommendations:

▶ ACP recommends that clinicians add a triptan to a non-steroidal anti-inflammatory drug (NSAID) to treat moderate-to-severe acute episodic migraine headache in outpatient settings for non-pregnant adults who do not respond adequately to an NSAID.

▶ ACP suggests that clinicians add a triptan to paracetamol to treat moderate-to-severe acute episodic migraine headache in outpatient settings for non-pregnant adults who do not respond adequately to paracetamol.

ACP also provides guidance to clinicians to consider counselling non-pregnant adults to begin treatment for acute migraine headache as soon as possible after its onset by utilising combination therapy: A triptan with an NSAID or a triptan with acetaminophen.

ACP also recently published a companion guideline, Prevention of Episodic Migraine Headache using Pharmacologic Treatments in Outpatient Settings, which addressed new recommendations for the prevention of episodic migraine in non-pregnant adults. In that guideline, ACP makes recommendations for clinicians to initiate monotherapy for episodic migraine prevention in non-pregnant adults in the outpatient setting as well as alternative approaches if initial treatments are not tolerated or result in an inadequate response. ACP prioritised treatments based on economic and patient values and preferences.

“Migraine headaches remain underdiagnosed and undertreated,” said ACP President Dr Isaac O Opole. “While there are many pharmacologic options available to adults with migraine headache, this guideline will help clinicians assess the best course of treatment for this patient population, incorporating the best evidence and always with consideration of patients’ preferences, to make shared decisions for cost-effective treatment options that are best for the individual patient.”

Both guidelines are available at: www.acponline.org/