New paradigms in the recognition and acute treatment of migraine.

It would be ideal if clinical decisions regarding acute migraine treatment could be made on the basis of three parameters: a critical appraisal of available scientific evidence, clinical experience (including knowledge of the individual patient and his/her attack characteristics), and, of course, patient preferences. Patients are likely to prefer agents that offer rapid relief, pain-free status within 2 hours, no recurrence or need for rescue medication, extended time to recurrence (if present), consistency of therapeutic effect over multiple attacks, oral administration. good tolerability, safety, and minimal drug interactions. Fortunately, a number of specific therapies now are available which place these objectives within the patient's reach. Ongoing barriers to optimal migraine care include underrecognition, underconsultation, undertreatment, restrictions imposed by insurance companies, and exaggerated concerns regarding the safety of the triptans. Overcoming these barriers is likely to prove a more important contribution to patient care than endeavoring to establish the relative merits of one triptan over another. We have described in detail a number of strategies for improving recognition and treatment of migraine. Many headache specialists now believe that recurrent episodes of disabling headache, with a stable pattern over years, should be viewed as migraine until proven otherwise. In the end, this may represent the most useful paradigm in the primary care setting, where time is of the essence. Studies to validate this approach are needed. Acute treatment intervention that is based on scientific evidence, clinical experience, and patients' needs and desires will provide better outcomes than those presently obtained. Preliminary evidence favors early intervention with oral triptans, and randomized, prospective, double-blind, placebo-controlled studies, ideally employing a crossover design, are required to confirm this. The US Consortium's evidence-based guidelines, the National Headache Foundation's standards of care, and the Canadian guidelines have applied the standards of scientific inquiry to the field of headache management and "translation" of these guidelines into practical instruments for clinicians through vehicles such as the Primary Care Network's Patient-Centered Strategies for Effective Management of Migraine should raise the general standard of care for patients with migraine. Last, but far from least, initiatives undertaken by the World Health Organization (WHO) will add credibility to the many layfolk and professionals who have struggled to present headache as a disabling disorder worthy of scientific investigation and aggressive medical management. The WHO states: "These common complaints impose a significant health burden ... Despite this, both the public and the majority of healthcare professionals tend to perceive headache as a minor or trivial complaint. As a result, the physical, emotional, social and economic burdens of headache are poorly acknowledged in comparison with those of other, less prevalent, neurologic disorders." Migraine is finally out of the closet.