S4:Ep10 – Attack Based Care For Migraine


Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.

This episode is brought to you by our generous sponsor, Impel NeuroPharma. 

Molly O’Brien: Hi, there. I’m Molly O’Brien, with the Association of Migraine Disorders, and this is Spotlight on Migraine. Thanks so much for joining us. 

Today’s topic: attack-based care. What is it? How can you plan for your treatments? We’re going to dive into everything you need to know about attack-based care. 

To do that, I’d like to welcome our guest, Dr. Thomas Berk. Dr. Berk is medical director at Neura Health and a clinical assistant professor at the department of neurology at NYU Grossman School of Medicine. He is a neurologist and a headache specialist. 

Dr. Berk, thanks so much for joining us today.

Dr. Thomas Berk: Thank you so much.

Molly: Really excited to get into this topic. So if we can start off in the simplest of ways, what is attack-based care, and is that any different than acute treatment?

Dr. Berk: I think that attack-based care is different for somewhat different people, and I think that people use that terminology and understand it a little differently. Anytime we think about treating migraine, we always think about, for the most part, the two sides of the same coin, which is prevention and acute treatment. 

When we think about attack-based care, for the most part, we’re thinking about how different different attacks can be and can vary for every patient, and whether there are specific features — whether it’s the severity of pain, whether it’s features like having aura or not, whether it’s the prolonged nature of a specific attack — that can help to guide whether a specific acute treatment is appropriate in each individual situation. So that’s how I like to think about it.

Molly: OK, and that makes sense. I feel like all people living with migraine have their plan, but maybe haven’t thought about it in terms of a formal way, like having a treatment plan.

Dr. Berk: Exactly, exactly.

Molly: OK. So, let’s start off with — we kind of got into this a little bit. You kind of mentioned different levels of pain, different symptoms. Let’s just put it out there: should all patients treat all attacks the same, or is there a different way to approach treating each attack?

Dr. Berk: I think that there are a number of different factors that people should think about when they are treating their attacks acutely. And I think that one thing that always hangs over somebody with migraine, that always hangs over their mind, is, “Oh, no, am I overusing an individual medicine? Is this something that I’ve taken too much of already this week, this month? Also, how many pills did my insurance give me?” And I have to work with that kind of limitation.

Even moving beyond that, there, I would say, are for the most part two general schools of thought with regards to migraine — for instance, when somebody experiences more or less features of migraine during an attack frame. So most people who have migraine, their attacks are not 100 percent stereotyped and oftentimes will appear more like a tension-type headache, without the throbbing and the nausea and the light and sound sensitivity. And when that happens, does that mean that they maybe shouldn’t use their triptans or not? 

So there actually is evidence for the use of triptans even for your not-as-obviously-migrainey attacks. When the triptans were first developed, one of the initial studies looked at the use of triptans for tension-type headache and showed that you can use triptans for tension-type headache for somebody who has migraine and not for somebody who has no personal or family history of migraine, where the actual process of migraine — the pathophysiology that we think about that happens in your brain during a migraine attack — actually oftentimes happens even when those features of migraine aren’t there.

So those are the different things that patients should definitely think about when their attacks happen: How different is it from their classic attacks, and also are there other medications, other options, and are they overusing?

Molly: OK. All great points to think about. You hit all the nails on the head: “Do I have enough medication to get me through? Does this attack warrant using my abortive medication, or should I try some other options first?” So those are all the things we have to consider, being a migraine patient. 

So I’m curious too — one more thing to add to the list of things to worry about and stress about — are treatments more effective if we use different options for every attack? So say I use Tylenol for one attack, my triptan for another, my gepant for another, rather than just continuing to use my triptan for every single attack.

Dr. Berk: There are reasons to alternate, and there are reasons to be consistent. And I think a lot of it is very individualized, and I think so much, in general, of migraine treatment is highly individualized. So if you’re somebody who, first of all, is not experiencing a very high-frequency migraine, where you are not, let’s say, at risk for developing more medication overuse or rebound because there’s a medicine that you’re taking so frequently acutely, then that may be a reason to be more consistent. If you notice that some of the medications that you use are consistently effective and some less so, that’s definitely also typically a reason to use that somewhat more often.

There actually is evidence to throw in some longer-lasting anti-inflammatory-type medications like naproxen or nabumetone, that those may, if anything, be protective against developing medication overuse. So if you’re somebody who uses a fair amount of triptans and the question is are you starting to develop rebounds now because of it, adding in and alternating an anti-inflammatory together with it, especially a longer-acting one, can definitely be helpful. 

So I would say that if you’re able to find a consistently effective treatment, it’s usually better to rely a little bit more heavily on that consistently effective treatment. If there’s still lingering nausea, that might be a reason to add on or even start with an antinausea-type medication like metoclopramide or even ondansetron, Zofran. Those medications can definitely help with those symptoms also. 

So those would be reasons to add on medications even if you could find a very effective, consistent medication.

Molly: That’s great, and it’s funny because it’s so tricky to talk about these kind of things on a broad spectrum because every patient is so different and every attack is different too. So thank you for narrowing it down and also keeping it broad enough to apply to all of us. 

So you mentioned, too, talking about rationing medication, which can be frustrating, whether it’s for the amount that you have, the amount that insurance clears, or just the cost itself. You don’t want to run out because it could always be worse. So let’s talk a little bit about that. For people who might be thinking, “I have to ration this certain medication,” do you have guidance on helping patients make these decisions on what to take for each attack?

Dr. Berk: It can be very, very tricky. And, oftentimes, when you’re really rationing medications, sometimes you will make those decisions where you’ll say — if it’s a triptan, for instance, and your insurance company is only giving you sometimes eight, or I’ve even seen insurance companies where you’re getting four in a month — obviously, appealing to the insurance company, telling them that this is beyond ridiculous. If you’re giving somebody four triptans, you’re literally allowing them to treat two migraines over the course of a month.

In general, I think it’s worth saying that there, I don’t think, are any other medical conditions where the insurance company gives you fewer medications than would be appropriate on or as needed basis. Nobody is giving their patients fewer blood pressure medicines. If you had even asked for some of the medications that are very inappropriate and lead to very high incidents of something like rebound or medication overuse — they’ll give you four rizatriptan, but they’ll give you 500 butalbital pills, and clearly there’s something very wrong about that. So I definitely, at that point, would talk to my patients about how to best think about some of their treatments.

If you only have a few triptans, then sometimes, honestly, using those after an anti-inflammatory or after an antinausea medication may be necessary. Sometimes, using that primarily as a rescue after you’ve tried a few different medications sometimes again can be necessary. 

Sometimes you’ll have an insurance that will allow you to have four of one triptan and four of a different triptan. And then, obviously, you don’t want to overlap triptan use, but at least you’ll be able to give your patient a few different options with regards to something that’s more specific for migraine.

Molly: OK. And you just touched on nausea, kind of when and where to hit that. I’m curious: in your practice, if people have different symptoms like nausea, vomiting, or aura with their attacks, does that impact what you prescribe and what people should take in different attacks?

Dr. Berk: It very much does, yes. If you’re somebody where nausea is one of the primary symptoms of your attack, then I strongly feel that having an antinausea medication — even if you don’t necessarily need it for every single attack, but maybe if you’re still experiencing nausea after you’ve used that first treatment, whether that’s a triptan, whether that’s an anti-inflammatory — can be very helpful.

Oftentimes, in almost every situation, taking an antinausea medication would not be contraindicated at all, even together with whatever that other first-line medication would be. So, yeah, definitely, adding an antinausea medication can be very helpful.

Molly: And we know that most migraine drugs work best when they’re taken right away. That also is difficult when it comes to timing and thinking about what option you should do. So, again, it’s very tricky, all this. 

So if someone misses their window for that attack treatment — say it’s a triptan, so say they miss the window where that’s going to be most effective — do you have recommendations on what people should do?

Dr. Berk: Sometimes, using some of those longer-acting, longer-half-life medications can be more helpful. And, just in general, to talk about early treatment, when we say “early treatment,” it doesn’t necessarily have to be that you’re taking specifically a triptan early. You can try to take anything early. Early treatment, early intervention of a migraine with just about anything, is going to be much more helpful than doing nothing within those first few hours of the migraine.

In general, the way I like to think about it is if the migraine has been allowed to settle in your brain for two hours plus, it’s just that much more difficult to pry off of your brain. It’s sunk its tentacles in, and it’s in there for the longer haul. So absolutely some of the longer-acting — sometimes triptans. That can be naratriptan or frovatriptan. 

Gepants oftentimes can be very effective in that situation also. So, obviously, if a gepant is your go-to medication, you do want to take it early. But if you haven’t, I would say that doesn’t necessarily decrease the effectiveness of the gepant as significantly as some of the other medications. 

And, like I mentioned before, some of the longer-acting anti-inflammatory-type medications like naproxen, nabumetone — that class of medications oftentimes can be still very effective longer-term, even if it’s been a while since the migraine started.

Molly: I like that visual, sinking its tentacles into your brain. That’s such a good visual, and that’s really what it feels like.

Dr. Berk: A little gruesome.

Molly: It does. It just sucks onto that brain. I like to say sometimes I’m too deep into an attack for any of the stuff to work. But I do notice if I treat it earlier enough, some medications or some treatments, like a neuromodulation device, if I get it early enough, if I’m in tune and aware of my body, then it can nip it in the bud. So don’t let it sink into you.

Dr. Berk: Oftentimes, people will get a treatment-based protocol from their doctor and that acute treatment plan can kind of go one of two ways. Sometimes, it can be, “What medication do you take first? What medication do you take second? What medication do you take third?” And, sometimes, the focus – and, again, this should be very individualized — sometimes the focus should be if your pain is mild, if your pain is moderate, or if your pain is severe. And you can think about it in those two very different ways.

If you’re starting to experience migraine, and maybe it’s very mild at this point, sometimes the first intervention doesn’t necessarily have to be, like we were saying, the triptan. It sometimes can be — you know what? Maybe it’s because I actually was pulling an all-nighter, I was staring at my screen for hours on end because I’m really trying to get to a certain deadline or whatever it was, and I just need to take a break from that, and maybe getting some fresh air and relaxing your eyes, getting into a quiet environment, taking a few deep breaths. Maybe that’s all you need.

Sometimes people will use aromatherapy in that kind of situation. If it’s, again, in that more mild-to-moderate situation, using a neuromodulation device even before you’ve taken a treatment can sometimes be the difference between it going from mild to moderate or from moderate to severe and not. So, again, some kind of intervention — doing something, even a nonmedical intervention — can be very effective.

Molly: You make a great point about getting a treatment plan from your doctor. Is this something that patients can bring up if their provider doesn’t have suggestions? Just bringing up, “Hey, what do I do if it’s X, Y, Z, or what order should I take things?” Is that a good opportunity to establish an attack-based plan?

Dr. Berk: I would say you should try as best as you can to come up, together with your provider, with what to do in the situations that happen most frequently to you. And that’s why so much of this, really, is getting to know what your attacks look like and individualizing your treatment for that. 

You might be somebody where you have some more-severe attacks or less-severe attacks, and what should you do in either of those situations? You might be somebody where you have a consistent treatment, but in those situations where it doesn’t work, then what should you do? Because you might feel completely hopeless. You rely on sumatriptan, and it works 90 percent of the time, and here you are, and it didn’t. And now what are you supposed to do? So thinking about those eventualities and discussing that with your doctor is extremely important.

And, a lot of times, it can be a little bit papered over with, “Just take this when your migraine happens, and do this to help prevent it,” and, obviously, getting your doctor to know your attacks a little bit better. And that’s certainly what we always try to hone in on for our trainees, for our residents and fellows, thinking about individualizing that kind of plan. That’s what can be very helpful.

Molly: I love it. That is great advice. And you mentioned what do we do if this works usually every single time and then it doesn’t. Having a plan of what to do next, that can be so valuable. 

And it also makes me think about what to do if your healthcare team is not accessible. So, sometimes, not every office is open on the weekends. So what do you do then? So who do you call if you need help? Do you have advice for patients? They have an attack that goes into the overnight hours where they can’t get a hold of someone, or it’s on the weekend and maybe they don’t have access to their medical team or their medication’s not working.

Dr. Berk: I think that, you know, they say, “An ounce of prevention is better than a pound of cure.” So even potentially discussing that when you’re meeting your doctor, certainly, for the first time, and one of the things you’re definitely going to want to know is, “So how do I get in touch with you? How do I get in touch with people in your office?” 

And it may be, and I would say, most offices have a system where there is somebody covering, and it can be one of the other doctors. Sometimes, if it’s a general neurology practice and there are some headache specialists and some people that might be dementia specialists, it might be somebody who is trained in general neurology. But speaking to the doctor and having a good idea as to who might be on call — you might get lucky. It might be your doctor on that weekend. 

But, certainly, when you are discussing what to do for migraine, when you’re discussing acute treatment with your doctor, I think it’s very important to think about not just a medicine to take, but thinking about nonmedical treatments that may help you and thinking about a rescue treatment. That way, you do have options for those eventualities too.

So, oftentimes when I would — say, I’m writing most of my notes, especially if I’m writing up something that I’m giving to the patient — and that’s always, I would say, something that I recommend to most of my doctors, to have something. And now with newer legislation over the past year or so, patients have access to all of their notes. So sometimes it might be written actually in a kind of patient-friendly way at the end of their notes. I try to break it down: What are the nonmedical treatments that are effective for you? 

And that usually would include something like calendaring, which isn’t necessarily part of this acute treatment plan but will help us in the future. Oftentimes, if I’m meeting somebody, I’m just getting to know you, and we need to actually spend some time figuring out what your attacks look like. Sometimes you’re in so much pain and discomfort that you don’t even know what your attacks really look like.

The other things to think about when we talk about nontreatment plans can be whether it’s something to add on acutely, like breathing exercises and biofeedback acutely, meditation, aromatherapy, even preventively thinking about what supplements might be appropriate or not — again, all of these things based on your situation, sometimes even exercise. 

It definitely can be problematic if you don’t have access to your doctor. It’s very important sometimes that you do. And like I said before, an ounce of prevention is better than a pound of cure. So having all of this information, or at least as much of it as possible, as you’re leaving that initial doctor’s appointment can be so helpful.

Molly: I think that’s such a great point too, to be able to access that. I know when, in the midst of a really bad attack, I’m not thinking straight. The brain fog is too much, so to think, “OK, well, this is the first step, this is the second step” — right. So to be able to have that either on your computer or on a piece of paper, you know where to go to find it, because all that information can get muddled. So that’s a great point, to have patients have access to that information.

Dr. Berk: Absolutely.

Molly: All right. Well, Dr. Berk, this has been such an excellent conversation. I know you’ve really educated me a lot in attack-based care. Is there anything you want to share with our followers all about attack-based care?

Dr. Berk: I think that one thing is ask your doctor if you’re not sure what to do in any of these eventualities, and being prepared is super important. So if you are going through your acute treatments with your doctor and there is something that you’re not sure about, don’t be ashamed to ask. That’s what we’re there for.

And it’s always, also, easier to answer a question when we’re there with you than in the middle of an attack when the last thing that you want to do is call your doctor, and especially if it’s on the weekend or the middle of the night. So ask and ask and ask. And if there’s something that you’re not clear about or you’re really not sure about, definitely ask.

Molly: That’s a great point. I don’t want to be calling at midnight to my doctor’s office, and you don’t want to be getting the call at midnight. No one wants that, so [if] you can work in to prevent that by doing it in the moment at those appointments or via telehealth or whatever, then it can go a long way.

Dr. Berk: Exactly, exactly. This is how to avoid that situation.

Molly: I love that. Well, thank you so much for joining us. And that wraps up this episode of Spotlight on Migraine. I’d like to thank our guest, Dr. Thomas Berk, for joining us. I know I’ve learned a lot. I hope you have at home as well. Dr. Berk, thanks so much for being with us today.

Dr. Berk: Thank you so much.

Voice-over: Thank you for tuning in to Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.

*The contents of this podcast are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The speaker does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.