Migraine headaches: treatment limitations and opportunities

In recent years, migraine treatment options have expanded to the extent that the practicing clinician now has a myriad of pharmacologic agents in varied drug classes and delivery systems from which to choose. Drug classes most commonly employed for treatment of migraine attacks include non-migraine-specific agents, such as nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, barbiturates, combination analgesics, and antiemetics, and migraine-specific agents, such as triptans and ergot alkaloids and derivatives. Delivery options range from conventional, orally disintegrating, and rapid-release tablets to injection, nasal spray, and suppository. The US Headache Consortium offers guidelines classifying migraine treatments into different groups based on evidence of clinical benefit (Table 1). Clinicians must be aware of the advantages and limitations of each class and delivery system and possible opportunities to improve their usefulness in different clinical contexts.