Disease management of migraine and the importance of stratified care

Migraine is a common neurological disorder that remains under-recognized, under-diagnosed and under-treated. The disorder imposes a large burden on individuals and the wider community in terms of migraine-related disability and high healthcare and societal costs. Moreover, there is a discrepancy between the availability of effective pharmacologic intervention and the level of treatment that patients with migraine actually receive. A disease management program can benefit individuals with migraine and society in general, by delivering improved care within a cost-effective framework. Disease management programs aim to reduce the burden of illness by identifying key factors that influence disease outcome. Herein, we consider a clinic-based migraine disease management program. Currently, step care remains the most common approach to migraine management. However, this approach frequently delays effective therapy and leads to patient dissatisfaction and lapse from medical care. Stratified care is an alternative approach to migraine management and tailors the choice of therapy to the individual treatment needs of patients. The Migraine Disability Assessment (MIDAS) Questionnaire offers a simple and reliable measure of migraine-related disability. It assesses the overall impact of disease and reflects illness severity and thereby helps guide the physician to the appropriate treatment. Implementation of stratified care, based on illness severity assessed by a disability measure, increases the likelihood that patients with migraine will receive the appropriate treatment plan from the initial consultation. In a randomized trial, step-care and stratified-care approaches were compared using aspirin (acetylsalicylic acid) plus metoclopramide or zolmitriptan 2.5mg oral tablet for the treatment of migraine attacks. The study demonstrated that stratified care produced significantly better clinical outcomes and improved the cost effectiveness of healthcare delivery for migraine compared with step care strategies.