Is It Appropriate to Treat an Attack During Migraine Prodrome?

A Migraine attack can consist of up to four phases, including the Migraine Prodrome. The Migraine prodrome (sometimes called the premonitory phase) of a Migraine attack consists of multiple possible symptoms of various types preceding and forewarning of a Migraine attack by two – 48 hours, occurring before the aura in Migraine with Aura, and before the onset of pain in Migraine without Aura.

For a list of potential Migraine prodrome symptoms see Recognizing Migraine Prodrome is Helpful to Patients.

Unfortunately, the Migraine prodrome is poorly recognized and often overlooked, That’s unfortunate because the prodrome can give us warning that a Migraine attack is beginning and allow us to be as prepared as possible.

This brings up excellent questions such as “Should we take our Migraine medications during the prodrome?” and “Is the prodrome phase too early to treat a Migraine attack?” Although these questions haven’t been the subject of current research, from a presentation at the 53rd annual scientific meeting of the American Headache Society (June, 2011), it would seem that the answer is, “Perhaps treating during the prodrome is appropriate, and if so, the earlier, the better.”

During the conference presentation, Dr. Becker discussed two older research studies about treating during prodrome.^4,5

Luciani et al. looked at naratriptan (Amerge) for treating Migraine during the prodrome:

• 20 participants finished the trial
• The most reported prodrome symptoms were
  • change in energy,
  • change in mood,
  • irritability
  • food craving,
  • muscle pain / tenderness,
  • sleepiness,
  • change in nausea, and
  • change in appetite.
• During the baseline phase, which was used to record prodrome symptoms and whether a Migraine occurred, no treatment was used. Migraines progressed to the headache phase 100% of the time.
• Participants were instructed to treat with naratriptan when they had prodrome symptoms and felt a Migraine was “inevitable.”
• During the treatment phase, when symptoms were tracked and participants took naratriptan during the prodrome, the Migraine progressed to the headache phase only 40 percent of the time.
• Prodrome symptoms did reliably predict Migraine for nearly all participants.
• Participants were able to distinguish between prodrome symptoms that resulted in Migraine and similar interictal (occurring between Migraines) symptoms.

Luciani study conclusion:

“Naratriptan 2.5mg appears to prevent the headache phase of migraine when given early in prodrome. If headache ensues, there appears to be a reduction in headache severity… Use of naratriptan during prodrome has the potential to prevent headache, thereby reducing disability, and possibly, the need for daily prophylactic therapy.”⁵

Waelkens studied 19 participants with Migraine with aura.

• Each participant treated four attacks during the prodrome phase, two attacks with domeridome (a dopamine receptor antagonist with antiemetic and properties and actions to increase gastric motility) 30mg and two with placebo.
• No aura or headache phase occurred in 65% of attacks when treated with domperidone as opposed to 5% of attacks treated with placebo.

Summary and comments:

In both of the studies referenced by Dr. Becker, treating Migraine attacks during the prodrome phase was quite effective. These were both small studies, and under normal circumstances, no treatment recommendations would be made based upon them until larger studies replicated their results. However, it has been 29 years since the Waelkins study and 11 years since the Luciani study. Given the lack of funding for Migraine research, it’s unlikely that the larger studies will be conducted. If you experience prodrome symptoms that reliably predict a full Migraine attack, it’s worth discussing treating during the prodrome with your doctor.

For more information on prodrome symptoms and identifying them, see Recognizing the Migraine Prodrome.

Resources:

1. Goadsby, Peter J., MD PhD. “Premonitory Phase of Migraine – Biology and Clinical Characteristics.” Platform Presentation. 53rd Annual Scientific Meeting of the American Headache Society. Washington, DC. June 4, 2011.
2. Sprenger, Till, MD. “Premonitory Phase of Migraine – Insights into Primary Headaches from Functional Imaging.” Platform Presentation. 53rd Annual Scientific Meeting of the American Headache Society. Washington, DC. June 4, 2011.
3. Becker, Werner J., MD PhD. “Premonitory Phase of Migraine – Treatment of premonitory Phase of Migraine: What is the Evidence?” Platform Presentation. 53rd Annual Scientific Meeting of the American Headache Society. Washington, DC. June 4, 2011.
4. Waelkins, J. “Domperidone in the prevention of complete classical migraine.” J Br Med J 1982;284:944.
5. Luciani, R.; Carter, D.; Mannix, L.; Hemphill, M.; Diamond, M.; Cady, R. “Prevention of Migraine During Prodrome With Naratriptan. Cephalalgia 2000 20: 122. DOI: 10.1046/j.1468-2982.2000.00030.x.