The role of headache-related disability in migraine management: Implications for headache treatment guidelines

Recently published US Headache Consortium Guidelines recommend a process of diagnosis, patient education, and individualized treatment for the management of migraine. Clinicians are advised to base their treatment choice on attack frequency and duration, degree of disability, non-headache symptoms, patient preference, and prior history of treatment response, using a stratified approach to care. In stratified care, initial treatment is individualized based on an assessment of the patients' medical needs. One approach to stratification uses the Migraine Disability Assessment (MIDAS) Questionnaire to stratify patients into groups with different treatment needs based on the degree of headache-related disability. Stratified care was developed as an alternative to step-care approaches, which begin patients on nonspecific medication with gradual escalation until they obtain effective relief. Results from the Disability in Strategies for Care (DISC) study indicate that stratified care provides superior outcomes compared to step-care and that the approach is cost-effective, supporting the US Headache Consortium Guidelines. Stratified care may become the approach of choice for managing migraine in clinical practice. This approach increases the chances of providing appropriate therapy at the patient's initial consultation, sparing the patient a series of failed therapeutic efforts. The MIDAS Questionnaire provides a practical tool for helping to implement the recommendations of the US Headache Consortium Guidelines.