ADVANCES IN MIGRAINE MANAGEMENT

New drugs and better understanding of the patho-genesis of migraine ar e improving the outlook for patients with this debilitating disorder. This paper reviews recent advances and outlines our approach. Rational treatment of migraine begins with a detailed history to ascertain the frequency and severity of attacks and to identify ''triggers'' that c an be eliminated. Nonsteroidal anti-inflammatory drugs, isometheptene mucate, ergotamine, and metoclopramide remain the first-line agents to treat acute attacks; patients whose symptoms do not respond to these drugs may be candidates for subcutaneous sumatriptan or dihydroergotam ine. Inhalable preparations of these drugs,when they become available, should simplify their use. Patients whose attacks are frequent or int erfere with their life style should be offered prophylactic treatment with beta blockers without intrinsic sympathomimetic activity or calci um antagonists; nonsteroidal anti-inflammatory drugs, val-proate, anti depressants, and biofeedback also may be used. Corticosteroids and dih ydroergotamine are mainstays of treatment for prolonged or intractable migraine.