EHF consensus on effective migraine treatment and triptan failure

The European Headache Federation (EHF) published a consensus on the definition of effective treatment of a migraine attack and the definition of triptan failure. The new definitions can be useful in clinical practice to identify suitable individuals for novel acute migraine treatments and to standardise research on the management of acute migraine.

The need for a consensus arose from the lack of a standardised definition of triptan failure, according to Prof. Uwe Reuter (Charité University Hospital of Berlin, Germany), who presented the EHF consensus [1,2]. “When you talk to your colleagues, you find that everybody has their own opinion of what triptan failure is,” Prof. Reuter said. The various definitions used in the literature preclude solid epidemiological estimates of triptan failure and hamper the comparison of study results. The lack of response to 1 triptan during a single migraine attack does not justify the conclusion that response to all triptans will be poor; less than two-thirds of patients have a response in 3 out of 3 attacks. Triptan failure is also affected by factors such as dosing, timing, and formulation, as well as accompanying symptoms and medication overuse headache (MOH).

The advantages of defining triptan non-response are that it can 1) create a standardised algorithm for acute therapy in case of failure to 1 triptan; 2) identify a population of non-responders and provide them with guidelines-adherent treatment strategies; and 3) standardise definitions for clinical trials to study factors associated with triptan failure. The consensus process included a preliminary literature review, a Delphi round, and a subsequent open discussion by the EHF Expert Consensus Group.

Since triptan failure cannot be defined without defining response, the Consensus Panel first proposed a definition of effective treatment of an acute migraine attack. This definition is patient-centred. In contrast to clinical trials, the pivotal concept is patient-reported well-being. The definition of effective treatment reads: “Reaching within 2 hours of drug intake, and maintaining for at least 24 hours, a state of well-being, as defined by: a) improvement of headache from severe or moderate to mild or absent; b) absent or minimal disturbances due to migraine-related non-pain symptoms; and c) no meaningful drug-related adverse events.”

A migraine patient is considered a triptan-responder when the triptan they take is effective in at least 3 out of 4 acute migraine attacks. Triptan failure is defined as not meeting the definition of triptan-response. The Consensus Panel broke down this definition of triptan failure into 4 definitions:

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   1. Triptan non-response: Failure of a single triptan (i.e. not matching the definition of triptan-responder).
   2. Triptan resistance: Failure of at least 2 different triptans (i.e. both not matching the definition of triptan-response).
   3. Triptan refractory: Failure of at least 3 different triptans, including subcutaneous formulation (i.e. none of them meeting the definition of drug-response).
   4. Triptan ineligibility: Presence of an acknowledged contraindication to triptan use as reported in the summary of product characteristics. The main contraindications that may vary across countries and drugs include coronary artery disease or angina, peripheral artery disease, stroke or transient ischaemic attack, and severe renal and hepatic insufficiency. In this case, other treatment options beyond triptans are advisable, including NSAIDs, acetaminophen, or novel upcoming drugs such as ditans and gepants.

The preliminary literature review on triptans revealed a high heterogeneity in design, definition of outcomes, and results. This explains why most of the proposed definitions resulted from open discussion and personal experience of the Consensus Panel rather than from study results. The proposed definitions are primarily aimed at clinical practice for the assessment of acute migraine treatments. However, the definitions could also help to standardise research on the care of acute migraine.

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   1. Reuter U. EHF Consensus on “Effective Treatment of a Migraine Attack and of Triptan Failure”. PleSe 8, EHC 2022, 07–10 December, Vienna, Austria.
   2. Sacco S, et al. J Headache Pain. 2022;23(1):133.

 

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Posted on 5 January 20235 January 2023