Cady RK, Lipton RB, Stewart WG, et al. He indicates that when clinicians use stratified care, some patients who met minimal criteria for treatment success with aspirin plus metoclopramide may receive a triptan. Success in our trial was defined as achieving mild or no pain within 2 hours in 2 of 3 attacks. Stratified care is not only more effective but also more cost-effective than step care. Patients may require multiple visits to the physician and may receive many nonspecific treatments before receiving effective treatment.
Some patients give up before finding effective therapy.
Dr Cady is concerned that stratified care may lead to underuse of triptans. Cady states that we failed to value effective therapy early in the course of a patient's migraine history. In fact, stratified care is an approach for selecting effective therapy at the time of initial consultation. There is no evidence to support this opinion. We would welcome studies that address the influence of treatment on natural history.