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Mixing Sumatriptan
Richard B. Lipton, M.D. Innovative Medical Research;
Stamford, CTRoger Cady, M.D. Headache Care
Center; Springfield, MO
Posted July 2002
"Letters to the Editor", Headache 2002; 42:325

Dr. Kanieckiís recent article, "Mixing Sumatriptan: A Prospective Study of Stratified Care Using Multiple Formulations" adds to the literature on strategies of care in acute migraine management. In his study, patients who responded well to oral or intranasal sumatriptan were given the opportunity to treat with subcutaneous sumatriptan, either as initial treatment or as a rescue medication. The study showed that in over three fourths of attacks treated with subcutaneous sumatriptan, this medication was used as rescue therapy, not as the initial treatment. This open-label study supports the widespread clinical practice of giving patients options in the mangement of individual attacks.

As strategies of acute migraine care have developed, the terms we apply to these strategies have proliferated and become a potential source of confusion. The most widely discussed stategies include step-care across attacks, step-care within attacks (staged care), stratified care, and patient-centered stratified care. Step-care across attacks is based on the assumption that it is not possible to determine a patientís needs at the time of the initial consultation. All patients are started at the bottom of the therapeutic pyramid with a low-end acute treatment; treatment is escalated as necessary through a process of trial and error until an effective treatment is found or until the doctor or patient gives up. For step-care within attacks, treatment is escalated within the attack if initial treatment fails. In stratified-care, as originally defined, information available at the time of the initial consultation is used to guide the selection of an acute treatment likely to be appropriate for the patient.

In the best studied variant of stratified care, treatment selection is based on the Migraine Disability Assessment (MIDAS) grade; more disabled patients are given high-end treatment as the first intervention while less disabled patients are initially treated with low-end therapy. The Disabilities in Strategies of Care (DISC) study showed that this approach to stratified care produces better outcomes than either of the step-care strategies outlined above, using aspirin plus metoclopramide as the low-end treatment and zolmitriptan as the high-end treatment. In patient-centered stratified care, patients whose headaches range in severity are advised to select from two or more acute treatment options based on the characteristics and degree of progression of the individual attack they are treating.

What strategy did Dr. Kaniecki assess in his interesting report? At first glance, it appears that most patients used a step-care-within-attack approach, with subcutaneous sumatriptan used after treating with oral or intranasal formulations of sumatriptan. However, patients also had the option of using subcutaneous sumatriptan as the initial treatment. This distinction is important in that it gives the patient a choice of initial therapy. It is useful to distinguish between patient-centered stratified care and other stratified care strategies. Patient-centered stratified care is a treatment approach that warrants further study using a broad range of treatment options and appropriate control groups.

Irrespective of the semantic issues, the high rates of satisfaction with treatment in this study suggest that many patients currently treated with oral or intranasal sumatriptan would benefit from the addition of subcutaneous sumatriptan as a treatment option. Combining treatments is a widely used acute treatment strategy that merits additional research and broader clinical use.