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| |  DG DISPATCH - AAN: Stratified care more effective than stepped care for migraine By Richard Robinson Special to DG News
SAN DIEGO, CA -- May 2, 2000 -- Scaling first-line intervention to migraine severity produces better results than traditional stepped-care approaches, researchers report. As described by Richard B. Lipton, of Innovative Medical Research, in New York, NY, the standard of migraine intervention approved by most third-party payers begins with low-end treatments such as aspirin and metoclopramide, and only progresses to high-end triptan therapy for patients with insufficient migraine relief. However, Dr. Lipton explained, this stepped-care approach prolongs disability in those with more severe headache. Dr. Lipton presented his findings on Monday (May 1) at the 52nd Annual Meeting of the American Academy of Neurology, in San Diego, CA. Stratified care, on the other hand, provides high-end therapy right away to more severely affected patients, he explained. To test the ability of a stratified-care approach to reduce disability in migraine patients, Dr. Lipton and colleagues conducted a parallel-group study of 835 patients in 88 centers in 13 countries. Patients were treated with either 800-1000 mg aspirin plus 10 mg metoclopramide (low-end therapy) or 2.5 mg zolmitriptan (high-end therapy). Patients were randomized to one of three treatment strategies for treatment of up to six attacks. One-third received stepped-care across attacks (low-end for three attacks, then progressing to high-end if relief was inadequate); one-third received stepped-care within attacks (low-end at the beginning of attack, plus high-end at two hours if relief was inadequate); and one-third received stratified care, with initial treatment dependent on MIDAS (Migraine Disability Assessment Scale) score, a five-item patient self-assessment scale. Patients with a score of II received low-end therapy throughout the six attacks, while patients with score of III-IV received high-end therapy from the start. Results showed that the number of patients reporting moderate-to-severe disability at two hours after migraine commencement was significantly decreased in the stratified-care group compared to either of the stepped-care groups (p<0.001). Adverse events were slightly higher in the stratified-care group. Dr. Lipton noted that the severity of initial symptoms predicted treatment need, and said "disability at baseline predicted failure of low-end therapy in this study." In addition, he said, "In clinical practice, many patients started on a stepped treatment program lapse from care. Stratified care leads to getting patients on effective care sooner than the current routine clinical practice." He also noted that stratified care is one of the recommendations recently published in the journal Neurology by a consortium of seven groups, including general practitioners, headache specialists, and neurologists. The study, "Stratified care is a more effective migraine treatment strategy than stepped care: Results of a randomized clinical trial," was supported by AstraZeneca.
Related Link: AstraZeneca.
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