Predicting Inadequate Response to Acute Migraine Medication: Results From the American Migraine Prevalence and Prevention (AMPP) Study
Selecting optimal treatments for migraine to improve acute treatment outcomes in population samples requires knowledge of headache characteristics that predict success and failure of acute therapy. Pain freedom at 2 hours and sustained pain response at 24 hours are important outcomes of acute migraine therapy. Recently published results from the AMPP study provide a snapshot of the effectiveness of usual acute treatment as well as predictors of inadequate acute treatment response in a large population sample of people with episodic migraine. These results highlight the high rates of unmet treatment needs in people with migraine.
Dr. Richard Lipton and colleagues identified AMPP Study respondents who met criteria for episodic migraine and who self-reported currently using acute treatment for migraine. They assessed acute treatment success or failure at 2 hours and 24 hours post dose using questions from the Migraine Treatment Optimization Questionnaire (mTOQ).
- Two items from the mTOQ were used to assess migraine pain response outcomes following medication use:
- After taking migraine medication, are you pain free within 2 hours for most attacks?
- Does one dose of your migraine medication usually relieve your headache and keep it away for at least 24 hours?
- A total of N = 8233 responded to both survey questions
- 56.0% of respondents usually had an inadequate response to their regular acute migraine treatment at 2 hours suggesting substantial unmet acute treatment needs at the population level.
- 53.6% of respondents reported an inadequate 24-hour pain response
- Among the 44.0% of individuals who were usually pain free at 2 hours, 74.3% reported adequate response at 24 hours demonstrating that a good response at 2 hours was associated with doing well at 24 hours. This highlights the importance of initial response to treatment in overall patient outcomes.
Predictors for an inadequate 2-hour pain free response
- Male sex, being unmarried, and higher BMI.
- Among headache characteristics, average headache pain intensity and the presence of cutaneous allodynia were associated with inadequate response at 2 hours, but monthly headache day frequency was not.
- Depression was associated with an inadequate response, a finding consistent with the observation that depression is a risk factor for headache progression. Preventive migraine medications were protective against this outcome.
Predictors of an inadequate 24-hour pain relief response
- Considerable overlap with predictors of 2-hour pain freedom. While respondent sex was not significantly associated with 24-hour pain relief to acute medication, being married and having health insurance were both protective against an inadequate response.
- Tobacco smokers were more likely to have an inadequate 24-hour pain relief, perhaps because smoking may alter drug metabolism and shorten the duration of action of selected acute treatments.
- Similar to the findings with 2-hour pain freedom, average headache pain intensity and cutaneous allodynia were predictors of inadequate 24-hour pain relief, and, in addition, monthly headache days were also associated with an inadequate 24-hour pain relief. This may reflect the fact that more frequent attacks may be associated with prolonged activation of neuronal networks involved in pain processing during attacks, which may lead to lowering the threshold for subsequent attacks.
- However, the effect of headache days and of cutaneous allodynia independently predict inadequate 24-hour pain relief.
- Like the predictors of inadequate 2-hour pain freedom, depression was associated with increased odds of inadequate 24-hour pain relief.
- While acute medication overuse did not predict 2-hour pain freedom, it did predict 24-hour pain relief, perhaps reflecting the fact that individuals who overuse acute migraine mediations are at increased risk for headache recurrence.
Inadequate 24-hour sustained pain response among respondents with adequate 2-hour pain relief
- These outcomes most likely reflect headache recurrence. The sample size for this analysis was 44% of the total study sample (N = 3621).
- Cutaneous allodynia, monthly headache days, depression and acute medication overuse predicted inadequate 24-hour sustained pain response among respondents with adequate 2-hour pain relief response.
- High headache day frequency, cutaneous allodynia, and acute medication overuse may all be markers for sustained activation of migraine’s neurobiological underpinning.
“These results show that unmet needs remain and the expansion of therapeutic options for episodic migraine is needed as well as optimizing treatment by carefully designing comprehensive treatment plans with existing acute therapies with various doses, routes of administration, preventive and interventional treatment approaches, behavioral therapies, neuromodulators, and other empirically validated approaches to achieve optimized treatment.”