What Practice Challenges Do You Face in the Treatment of Acute Migraine?

Randolph W. Evans, MD


June 28, 2021

Headache specialists face many challenges and difficult decisions in the treatment of acute migraine. They must first accurately distinguish acute migraine from migraine mimics such as thunderclap headaches or a COVID-19 headache without fever. Acute treatment for migraine patients with comorbidities is also a great challenge. Triptans are contraindicated for migraine patients with coronary artery disease, peripheral artery disease, cerebrovascular disease, or uncontrolled hypertension. NSAIDs are contraindicated for migraine patients with peptic ulcer disease, gastric reflux, gastric bypass, or renal insufficiency. Pregnant patients and geriatric patients also require special considerations.

Dr Randolph Evans, of Baylor College of Medicine, offers a look at the challenges that he faces daily in the treatment of acute migraine. Evans examines the features of status migrainosus (seen in an estimated 3%-20% of migraine patients), an unremitting migraine attack that lasts more than 72 hours and sometimes from 3 to 10 weeks. According to Evans, one of the greatest challenges is that despite advances in classes of acute medications, including triptans, gepants, ditans, and combinations, there are still patients with intractable acute migraine.


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