When it comes to treating migraine, many patients start with an OTC painkiller, then take a triptan later if the painkiller doesn’t provide sufficient relief. This is called “step care.” That’s the most logical approach to most patients, but is not recommended by many specialists. The preferred, and most effective, approach is called “stratified care.” It means hitting the migraine with the most effective medications at the outset. For many of us, that means triptans or possibly another prescription migraine abortive, like Migranal, DHE, or a Midrin-equivalent (though if OTC painkillers are always effective for someone, that’s what they should stick with). In a study comparing the two methods, 52.7% of participants using stratified care were pain-free in two hours, while only 36.4% using step care were. In addition, the total time of disability was considerably shorter for those using stratified care. ¹

Stratified care is the preferred treatment because the further into a migraine attack you get, the less likely medications are to be effective. Taking triptans when the migraine was mild gave more than half of migraine patients total pain relief in two hours; waiting until the pain is moderate or severe gave fewer than a third such relief, according to one study. ² Another study found that patients who took a triptan within 15 minutes of the migraine’s onset reached the migraine’s peak in an average of 1.9 hours; it took an average of 8.9 hours in patients who waited to take a triptan until four or more hours after a migraine’s start. ³

For someone who has infrequent migraine attacks and good health insurance, taking a prescription abortive every time a migraine comes on is usually no problem. (Unless the side effects are bad, which will cause anyone to put off medications until they absolutely have to). It’s far less practical—and often impossible—for someone who has frequent migraine attacks, inadequate prescription drug coverage, or no health insurance at all to do this. Money is a factor, as is the risk of rebound (medication overuse) headache.

In an ideal world, we’d all start with the medications that are most effective for us, but that’s not an option for everyone. It’s best to weigh all the variables and talk to your doctor about which approach to care is optimal for you.

REFERENCES

1.Lipton, R. B., Stewart, W. F., Stone, A. M., Láinez, M. J., & Sawyer, J. P. (2000). Stratified care vs step care strategies for migraine: the Disability in Strategies of Care (DISC) Study: a randomized trial. Jama, 284(20), 2599-2605.

2. Lantéri-Minet, M., Mick, G., & Allaf, B. (2012). Early dosing and efficacy of triptans in acute migraine treatment: the TEMPO study. Cephalalgia, 32(3), 226-235.

3. Hu, X. H., Ng‐Mak, D., & Cady, R. (2008). Does early migraine treatment shorten time to headache peak and reduce its severity?. Headache: The Journal of Head and Face Pain, 48(6), 914-920.