MIGRAINE IN 1987

Janet is a 37-year-old cashier who experiences migraine headaches. In a typical example, she develops a migraine beginning on a Sunday morning. She takes her usual doses of ergotamine-caffeine, to no avail. She adds an OTC combination of aspirin, acetaminophen, and caffeine, followed by additional acetaminophen and ibuprofen. No better on Monday, she calls my office for an urgent appointment. After waiting on hold for 35 minutes, she receives an 11 AM appointment time.

I cannot get Janet's chart to review in time for her appointment because it is stored at another Kaiser clinic across town, so I call the pharmacy to learn her refill history. I ask my assistant to phone the hospital to learn if Janet has been visiting the emergency department (ED) for headaches. While my morning patients wait, we are both placed on hold for over 10 minutes. Janet takes a diuretic for hypertension as well as levothyroxine. I phone the lab for her latest test results, and I'm on hold for another 5 minutes.

When Janet arrives, I learn the history of the 24-hour headache and that she has been experiencing five or six moderately severe migraines monthly, including 1 day before menstruation. They usually last 8 to 12 hours with treatment, but sometimes they persist for up to 3 days. She has milder headaches nearly every day, which are usually manageable with aspirin, acetaminophen, and caffeine.

The examination room is dark when I enter. Janet is wearing sunglasses and is curled into a fetal position. Her weight is 110 kg, and her BP is 135/92 mm Hg. Her scalp is tender. The remainder of the examination is normal. I order 75 mg of meperidine and 25 mg of promethazine. I order amitriptyline, 25 mg HS, to reduce headache frequency and hydrocodone/ acetaminophen tablets to mix with ergotamine for severe migraines.

Janet returns in 8 weeks. The new medication seems to work better than ergotamine alone. She is unhappy, however, because she has gained 3 kg since her last appointment. She has visited the ED twice since I saw her, and her daily headaches have not abated at all.

MIGRAINE IN 2007

Janie, Janet's 30-year-old daughter, is also a migraineur. When she experiences a typical headache on a Sunday and two doses of rizatriptan 10-mg tablets—her usual abortive medication— do not relieve her symptoms, she goes online to the Kaiser Permanente Web site* and makes an urgent appointment to see me the following day.

Before seeing her, I review her chart in EpicCare, Kaiser's electronic medical record (EMR). I note that migraine without aura and obesity are the only entries on her problem list. I see that she is refilling her rizatriptan prescription with 9 tablets per month and takes no other prescription medications on a regular basis. One ED visit is recorded in the past 6 months for migraine. A single click in my panel management tool advises me that Janie is up to date on all health maintenance benchmarks.

From the history obtained today, I learn she is experiencing three or four migraines per month that typically last 4 hours if treated, including one episode 24 hours before menses. During the past few months she has been experiencing nonmigraine headaches 3 or 4 days per week, for which she is using OTC analgesics and butalbital compound. Her vital signs and neurologic examination are normal.

Concerned about Janie's gradual increase in headache frequency, I consult the Clinical Guidelines Page on the Kaiser intranet. There I learn that patients experiencing headaches more than 15 days per month who take abortive medications more than 2 days per week on a regular basis may have medication overuse headache. I recall that opioids are discouraged for use in status migrainosus or for migraines that do not respond to appropriate triptan dosing. Accessing Kaiser's electronic guidelines again, I find “Treatment of refractory headache in the urgent care setting,” which includes recommendations for parenteral medications including sumatriptan, prochlorperazine, dihydroergotamine, ketorolac, magnesium sulfate, sodium valproate, and metoclopromide—all better choices than meperidine and promethazine, drugs I have used with patients like this for nearly 30 years.

Noting Janie's obesity and frequent headaches, I search the guideline for recommendation of a drug that will reduce the frequency of migraine and result in possible weight loss. I learn that topiramate (an anticonvulsant and migraine prophylactic agent) fits those criteria. When I order the drug, a decision support tool prompts me to order serum creatinine and bicarbonate to monitor for topiramate toxicity.

Janie asks whether there is something “natural” she can take for migraine. I consult the Natural Medicines Database online and discover that both magnesium and riboflavin have been shown to significantly reduce migraine frequency, and I provide her with dosing instructions and the brand name of a product that combines these substances.

Her headache has nearly resolved 45 minutes after injections of ketorolac and metoclopramide. I include advice and educational materials on headache on her after visit summary, a written set of aftercare instructions documented in the EMR and provided to most outpatients. I have included basic information on medication overuse headache and links to Kaiser's Health Encyclopedia and Drug Encyclopedia, available at www.kp.org to anyone with Internet access.

Janie's rizatriptan prescription has expired. She signs onto www.kp.org when she gets home and orders refills by mail. The prescription is refilled by an automated robotic mail order pharmacy and is in her mailbox 48 hours after her online request is placed.

I want a headache specialist to review this encounter and make recommendations for treatment. I initiate an electronic internal referral to neurology for a chart review. The neurologist on call records treatment recommendations that reach my electronic inbox the following day. She suggests I immediately discontinue Janie's OTC analgesics and prescribe a 3-day course of naratriptan, a long-acting triptan that may reduce the rebound pain Janie may experience when she quits using the offending medications. In addition, the neurologist suggests I order naratriptan, 2.5 mg twice daily for use beginning 24 hours before each menstrual period and continuing for 48 hours, to prevent menstrual migraine (an off label use of the drug).

Janie fills the prescriptions for the new medications but wonders how soon she can resume using rizatriptan after finishing the 3-day course of naratriptan. Instead of phoning, she uses the www.kp.org site to send a secure patient message, which is entered directly into her chart and reaches my electronic in-box. I answer her question at the end of the day.

Two months pass, and Janie returns for her follow-up appointment. She is experiencing migraine only twice monthly, and rizatriptan is almost always effective. Her once near daily headaches now occur only 1 or 2 days per week, and she has stopped using analgesics. She lost 3 kg since starting topiramate and likes that she is doing something “natural” to treat her headaches. She expresses gratitude for her substantial decrease in headaches and improved quality of life.

THEN AND NOW

As the contrast in these cases demonstrates, triptans have revolutionized the treatment of acute severe headache. Newer formulations, such as rapidly dissolving tablets and nasal sprays, are better tolerated in patients with nausea and vomiting. Rescue medications, such as prochlorperazine and magnesium
sulfate, are highly effective for migraine and are not associated with the sedation and dependence problems of opiate analgesics. The development of migraine-specific drugs used for prophylaxis of headaches (eg, topiramate) and the recognition of the efficacy of complementary therapy (riboflavin/ magnesium) have also improved migraineurs' quality of life.

Medication overuse headache was a completely unrecognized entity in 1987. Butalbital compound, opioids, caffeine, and OTC analgesics are most commonly responsible for this syndrome. By discontinuing the offending substances, most patients will recover from near daily headache. This pain syndrome can be difficult to manage and often requires intervention by a specialist in headache management.** 

Janie's case exemplifies the impact of the Internet on enhancing access to health care and medical information for both patients and providers. Perhaps the most significant difference in my approach to these two migraine patients was my current ability to search online for the answers to patient-specific questions and retrieve, in a matter of minutes, evidence to guide my decision-making. This instant access to evidence has truly changed the face of medicine. JAAPA

Eric Schuman works in the Department of Neurology at Kaiser Permanente in Salem, and Portland, Oregon, and serves as Adjunct Assistant Professor at the Oregon Health & Science University Physician Assistant Program. He has indicated no relationships to disclose relating to the content of this article.

* Bold phrases refer to ideas, therapies, and diagnoses that did not exist in 1987.

** The author is not the only PA who specializes in headache management. Two others are J. Michael Jones, who practices in Washington state, and Robert Hamel, at the Michigan Head and Pain Institute.