Patients initiate treatment with a low-end treatment such as a simple analgesic, but have access to multiple treatment options. If symptoms persist, therapy is ‘stepped up’ to a migraine-specific medication at an agreed time point (i.e. after a few hours). Thus, treatment continues to be escalated, within an attack, until an effective treatment is identified.
Although this approach provides patients with greater opportunity to exert a level of control in response to their symptoms, as with step care across attacks, the patient is denied the opportunity of an early treatment benefit.
Treating early in the course of an attack has been shown to be an important factor in the management of migraine; recent evidence suggests that treatment with an oral triptan early in the course of an attack, when headache pain is mild, is more beneficial in terms of patient outcomes than waiting until headache pain is moderate or severe. [60]
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