Risk Factors for Migraine and Migraine Progression—Lessons Learned From Epidemiologic Studies

Acetaminophen remained the single most widely used medication for acute migraine treatment. OTC medications were not strongly associated with an increased risk for chronic migraine; this included OTC medications that contained caffeine. Findings on NSAID usage confirmed the early FrHE observation that migraineurs commonly use OTC treatments for their headaches, said Dr. Lipton. About 3,600 were taking NSAIDs; the larger the NSAID dose, the less likely patients who had low- or moderate-frequency migraines were to progress to chronic daily headache, and the more likely patients who had high-frequency migraines (10 to 14 headaches per month) were to develop chronic daily headache.

Dr. Lipton offered two possible explanations: There is a major confounding effect for which he and his colleagues have not adjusted, or NSAIDs protect against migraine progression in people with moderate migraines; by the time that these patients reach high frequency, the disease is too advanced for NSAIDs to be protective. Ibuprofen and naproxen were the two NSAIDs most often used in this patient population.

Triptans, which are often prescribed for the most severe migraines, were not associated with an increased risk for migraine progression, but barbiturates and opiates were. Patients who took barbiturates were 1.7 times more likely to develop chronic daily headache (the effect was more pronounced in women), and patients who took opiates were 1.44 times more likely to progress (this effect was greater in men). In assessing whether barbiturates and opiates caused progression or were a marker for progression, the researchers determined that these drugs cause harm. Although triptans did not result in progression to chronic daily headache, the researchers determined that triptan usage is a risk factor for progression to chronic daily headache among persons with high-frequency headaches.

Dr. Lipton also reported that persons who experience zero to four headache days per month and take barbiturates one to three days per month appear to have a relatively low risk for chronic daily headache. People with very frequent headaches—even those who are not taking a lot of barbiturates—seem to have a substantially higher risk for chronic daily headache. The greater the opiate usage in people with high-frequency migraines, the higher their risk for transition to chronic daily headache, he said.