Director, MedStar Georgetown Headache Center, and associate professor of neurology, MedStar Georgetown University Hospital

Jessica Ailani, MD

 When we’re talking about prevention, when do we start considering preventive treatment? Rebecca, I wonder if you have some words to share with us about prevention? What are the goals of preventive therapy? When do we start considering prevention in our patients?

 This is such a great question. When we’re thinking about preventive therapy, we’re targeting the headache in terms of the frequency, the severity, the duration, and disability. On top of that, 1 goal is to decrease the likelihood of a headache happening. But when headaches do occur, we want to ensure that patients are able to be responsive to their acute treatments. Many times, when our patients get on a good preventive option, it not only decreases the frequency and the severity of their attacks but then makes their acute treatment options even more powerful, so they become more responsive to acute treatments.

In addition, we want to improve overall function and reduce disability, so patients are able to live their lives despite having migraine. One other thing that’s important is improving the overall quality of life and decreasing the psychological distress and health-related distress associated with migraines. We often start thinking about preventive treatment when patients are having headache attacks that are frequent enough that we start thinking about preventive along with disability.

There’s a range when we start thinking about whether to offer or consider preventive treatment options. When we think about offering it, we think about 6 or more headache days a month with no disability, 4 or more headache days a month with some disability, and 3 or more headache days a month with severe disability. This is the recommendation from the most recent American Headache Society Consensus Statement. But the way I remember it is basically 1 a week. If patients are having about 1 headache a week, that’s the point at which many preventive treatment options should be considered. I’m often surprised at how many patients are having attacks 2 or 3 times a week. They’re taking over-the-counter medications and will begin saying, “I’m not sure about taking a preventive.” I acknowledge that, but you’re taking over-the-counter medications that have adverse effects and risks with the frequent use that you’re using. It’s a transition to a preventive option at that point.

 It’s funny when you talk to patients about their over-the-counter medication use. What happens is patients are used to what they know, so we’re introducing the idea of what is unknown vs what is known; it’s that fear.

You make a very good point about disability. What is very well known to the patient is their disability in the burden of their disease. If we turn the conversation to their disability and the burden of their disease, sometimes that strikes a note, and it makes it easier to talk to them about prevention. Stephanie, do you have any tips on how you can have that conversation about the impact of the burden of disease with a patient and the impact of the quality of life? You’re seeing many refractory patients at the Jefferson Headache Center, which is a tertiary care center for headache specialists sending patients over, so sometimes you’re seeing the most burdened. How do you have that conversation and get patients to understand that burden?

Stephanie J. Nahas, MD, MSEd, FAHS, FAAN:

 First, you have to have it in the forefront of your mind that this is an important question. We focus so much on headache days per month and migraine days per month. That’s what the clinical trial primary end points are all about— reduction in mean monthly migraine days. We look at other things like reduction in acute medication use, function, quality of life, etc. But that stuff is what’s most important in helping you understand how migraine is affecting that individual. Our patients have no trouble verbalizing this and expressing it. It’s almost a given when they come to us, most of the time, but not exclusively.

But many clinicians out there may have to drag this out of their patients because they don’t necessarily want to admit how much migraine is affecting them. When you have these conversations, you’d better be prepared for some emotionality. This is 1 of the reasons we always keep tissue boxes in every office, because it could be quite a gut-wrenching discussion.

If you want 1 simple question to ask your patient to start this conversation, it’s a brave 1, but I suggest you put it into your armamentarium. Simply ask them, “What would your life be like without migraine?” If they give you a quick short and sweet answer, maybe they don’t need prevention. They just need some coaching and a good acute treatment. But most of your patients will start to go on a litany of reasons and changes in their life that they could see, a litany of concerns that they have because of their unpredictability of attacks that could take them out of the worse possible moment.

These are the things that go through patients’ minds between attacks. It speaks to the importance of assessing patients in their interictal period. Don’t focus just on headache attacks and headache days. What’s happening on the other days? Are they limiting themselves because they’re afraid they’re going to bring on an attack? Have they changed their life trajectory because they have this disease that has made them unpredictably incapacitated? We have plenty of patients who said, “I had to choose a different career,” or “I didn’t have as many children.” It’s far reaching, and it can be pervasive how a migraine can affect somebody and weave its way into every aspect of their lives.

 You reminded me of a publication. Chris, I wanted to bring this to you because you’re nodding along. Just to briefly mention, a publication I read not long ago reminds me of many of my patients. This publication was mentioning the number of women who decide not to have children because of migraine. Many of our patients have made the decision to be a surrogate parent or decide not to have children because the burden of disease is so great.

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Expert neurologists share their goals and patient considerations for preventive migraine therapy.

Goals of Preventative Therapy for Migraine

 titled “The Changing Landscape of the Preventive Treatment of Migraine.” I’m Dr Jessica Ailani, a professor in the department of neurology at Georgetown University Medical Center in Washington, DC. Joining me in this discussion are my good friends and colleagues Dr Andrew Charles, a professor of neurology at the [David Geffen] School of Medicine [at the University of California, Los Angeles]; Dr Stefanie J. Nahas, an associate professor in the department of neurology at Thomas Jefferson University [Hospital] in Philadelphia, Pennsylvania; Dr Christopher Gottschalk, an assistant professor of neurology at Yale School of Medicine in [New Haven] Connecticut; and Dr Rebecca Erwin Wells, an associate professor of neurology at the Wake Forest School of Medicine in Winston-Salem, North Carolina.

Welcome, everybody. I’m so glad to have you all with me. You’re all in for an amazing treat because there’s no better way to discuss the treatment of migraine than with a bunch of friends who love to have discussions and arguments about what we should do to take care of our patients with migraine. Today we’re going to discuss a number of topics that pertain to the paradigm shift in the treatment strategies to manage and prevent migraine. Let’s get started with our first topic.

We’re going to talk about the evolution of migraine preventive therapy. Let’s talk first about the historical perspective and where we’ve been in migraine prevention. I want to talk first to Dr Andrew Charles. Andy, can you tell us about some of the agents we’ve typically been using with migraine prevention? What have you seen with their use in the patients you take care of day to day?

Thanks, Jessica. It figures that you start with the old guy to talk about the history. But I’m in a good position to talk about some of our historical perspectives. Traditionally we’ve had what we would call nonspecific therapy for migraine. These were therapies that were developed for other indications and co-opted for the prevention of migraine. These therapies fall broadly into 3 or 4 categories. There are the anticonvulsants, topiramate and divalproex sodium. Then there are the antidepressants, the tricyclic antidepressant, and also potentially SNRIs [serotonin and norepinephrine reuptake inhibitors]. Then there are the antihypertensives, beta-blockers, and candesartan, and we can put Botox in there because that has been around for quite some time, although we’ll talk about that as a newer therapy for chronic migraine.

These traditional therapies are in our practice. We certainly have people who respond to each and can respond quite nicely. One major issue is that we have very little way of predicting who’s going to respond to which therapy, so we end up choosing based on comorbidity. If an individual has trouble sleeping; we’ll use a tricyclic. If they’re hypertensive or anxious, we might use a beta-blocker. If they’re having weight issues, we might use topiramate. But these are related to comorbidities rather than actual treatment of migraine.

The other issue is that they all have fairly significant adverse-effect profiles that we have to deal with. Part of our management is balancing the adverse effects with the beneficial effects while using these traditional therapies. That’s what I would put out there as a historical perspective.

 You make some good points about the balancing of the adverse-effect profile, which is an important aspect. When we’re thinking about some of our historical medications, it’s not that they’re not effective; it’s the tolerability. That’s a concern patients have when we’re talking to them about preventive treatment.

Andrew C. Charles, MD, provides a historical perspective on the agents traditionally used for preventive migraine therapy.

Migraine: A Historic Perspective on Preventative Therapy

“[The migraine section of IFN] is a hybrid-type session, and I’m excited to see how that goes, because I have a feeling this is really the future of how conferences are going to be looking.”

International Congress on the Future of Neurology (IFN)

, held from September 17-18 at the InterContinental New York Barclay, will feature presentations on the most recent advancements in neurology, including migraine and headache. Jessica Ailani, MD, director, MedStar Georgetown Headache Center, spoke with 

 on the areas she is excited to see discussed. 

Ailani, who will be running the section focused on migraine therapy, commented on the hybrid aspect of this year’s conference, with attendees able to visit in person or tune in virtually. Areas of interest for Ailani include the opening keynote lecture, given by Stephen Silberstein, MD, on new devices in migraine prevention and treatment. Silberstein, who the director of the headache center and professor of neurology at Jefferson Health, will speak specifically on neuromodulation, an area that has generated a large number of questions in both the patient and provider communities. 

When asked about upcoming “hot topics” Ailani called attention to the novel calcitonin gene-related peptide treatments and how experts are making use of them. She further commented on treatment options to be discussed at IFN 2021 for patients with migraine, including acute treatment, preventive treatment, and nonpharmacological options such as behavioral therapies. 

. For more information and to register for the meeting, 

The director of the MedStar Georgetown Headache Center discussed the upcoming International Congress on the Future of Neurology and what attendees can expect to hear from experts in migraine. 

What to Expect at IFN 2021: Jessica Ailani, MD

As June quickly approaches and the southeast coast is drenched in humidity and cicadas, National Migraine and Headache Awareness Month is upon us. One of my favorite events every June is the American Headache Society annual meeting. For a headache specialist, there is no better way to ensure you are up to date with the latest in headache research and celebrate awareness of the disease states we care for daily. This meeting always reinvigorates me to come back to my clinic, battery charged and ready again to make the lives of my patients better.

The American Headache Society Annual Scientific Meeting will be virtual this year to continue to keep safe through the pandemic. While many of us are looking forward to a time when we can be together in person again, there will still be many great events in which we can discuss interesting lectures and abstracts, as well as share research ideas and work together to make the future of headache brighter.

Although networking through virtual lounges does not replace meeting in person, it does allow us to connect with each other and discuss our favorite talks. It also allows for some of my favorite parts of the meeting to occur—debates! Since nothing in medicine is a complete guarantee, I always feel growth comes from our ability to discuss our different points of view and to allow ourselves to be convinced that someone else may be right. The scientific meeting this year will also host 2 formal debates during the program: 1. Should chronic migraine be a separate diagnosis from migraine; and 2. should the criteria for tension-type headache be changed? I always find these debates to be the most entertaining and never end up taking the side I thought I would at the start.

There are many other presentations I am looking forward to, 2 of which are our keynote presentations. The first keynote is on genes, stress, and resilience by Huda Akil, PhD. In a year where we have all been under tremendous stress, I am looking forward to learning more about the science behind resilience. Our second keynote is on how we can learn from other specialty clinical trials to improve diversity in headache research by Richard Benson, MD, PhD. He has extensive experience in stroke clinical trials and has focused on increasing diversity in these trials. We have struggled as a field in being able to increase diversity in headache clinical trials. Personally, I could use some expert tips to improve not only recruitment, but retention, of a diverse patient population into our trials.

Other hot topics in headache science that will be discussed include vaccines and their impact on migraine, contributors to chronic migraine, calcitonin gene-related peptide and its action on the normal and traumatic brain, central nervous system circuits, the descending pain pathway, the nitroglycerin model, cognition and pain processing, sex differences in pain…the list just keeps going and it’s hard to say which session is better—in fact, I invite you to come and participate and let us know what you think!

As you enjoy the start of the summer season, hopefully finally meeting up with friends and family, consider enjoying the offerings of a virtual meeting.

. To register for the American Headache Society Scientific Meeting, 

Articles

With the AHS 63rd Annual Scientific Meeting set to kick-off virtually on June 3, 2021, Jessica Ailani, MD, FAHS, offered her perspective on what to expect from the presentations and sessions.

What to Expect From the 2021 American Headache Society Annual Scientific Meeting

 I think the important thing for people who are listening to this segment is that there are some very exciting, new medications out there. Dr Ailani, once you have made the right medical decisions for patients, how often do you hit a stumbling block with insurance coverage where you know, as a clinician, that this is what the best treatment option for the patient? Do you have any options to have a trial of these medications prior to insurance coverage, so that you can say, “Well, look, let’s give you a few months as a trial before we try to fight for authorization,” or is that not even an option?

 We hit stumbling blocks almost all the time, to the point where I feel like I’m an expert at navigating crazy ways to avoid these situations. There are sample options available for patients, but my biggest issue with sample options is that they are a temporary fix. Many times, when dealing with the insurance issues, you can end up in a situation where the temporary fix is going to go on forever. Very quickly I have learned not to rely on that, but to figure out and invest the time into the insurance issue on the front end. Try to figure it out. I use samples to start patients off when I know that this is a medicine that is going to get covered, or if there is a problem with a dose, especially if a medication is an injectable, and the injector did not work, or somehow they left it out, or something got skipped by mistake, or there is a lag in insurance coverage to use it. This can help the patient through those situations.

Many times, on the back end, something I think patients do not realize is how much time our staff is spending on these claims; they are calling and submitting, and calling and submitting again, and writing. What does help us is honesty at the front end about what medicines the patient has taken and the adverse effects they have experienced. It is important to be patient about the time it does take to navigate the system. Knowing what drugs are on the patient’s insurance formulary is very important.

It seems to me that, with so many medications—not just in your specialty but across the board—we have to go through this game of trying things that we know are not going to help patients, just to tick a box to say, yes, the patient has failed this treatment. At the end of the day, yes, it is wasting a lot of time and it distresses the patients, but I so often feel that that in itself wastes so much money. There is a cost in terms of a patient’s quality of life, but if a patient is having excessive tests, more scans, more admissions, more days off work—it just does not make sense financially, but we get stuck in it. Is there any advice you can give to patients that may help expedite getting approval? It must be very difficult when patients are keen to get on these medications as soon as possible. Do you find that approval, for example, is more likely to be granted if it is coming from somebody like you who can argue the case more effectively?

Actually—this is something I tell my patients and they do not believe—but it is more likely to work if the patient picks up the phone and starts to call the right people on the insurance side, and if they write letters. I find that what has happened over time is that the insurance does not really care what we have to say; they care about what the patient has to say. After a denial and then a denial of an appeal, they care what the HR [human resources] department of the person who has the insurance has to say. It is best if, early on, we are engaging the patient who—if it is the spouse’s insurance, then the spouse’s HR at their place of employment, having them call the insurance company. That is how we get a lot of our medications through. You have to educate the patient on this, and they do not believe us because they think that we have all this power, but we don’t.

 Right, no doubt there is also some belief that we are passing the buck back to the patient, to do the hard work. It is very encouraging to hear that the patients picking up the phone can actually have an effect. Do you find that when you receive denials from these companies about approval for CGRP [calcitonin gene-related peptide] inhibitors, you get a reason or something explaining, “Well, we are denying it, and this is why.” If so, what is the reason for denial?

Well, sometimes the denials are based on if the patient has not tried the appropriate therapies. They have not tried everything on the formulary. They say, “We cannot guarantee they are not taking X, Y, or Z.” Once I got a denial, a few times I’ve seen this, where they said that they cannot guarantee that the patient is not taking another CGRP monoclonal antibody, when the patient has already stopped that medicine. That to me, is the most frustrating thing because you are the insurer, and you see the pickup medication history. 

That makes me sometimes wonder, so I have to call the patient and say, “Did you pick up this medicine in the last 3 months? I thought you stopped it.” They will say, “I haven’t picked it up from the pharmacy.” To me, it is just a way to put up a stopgap because clearly the insurance company knows it is not being picked up, but they just provide another reason for the denial. Today we got one that said because the patient has been on a CGRP monoclonal antibody for 6 months, they are no longer allowed to get their triptan, because according to the insurance company, they should not need it as they are on a preventive, which is not a cure for migraine, but….

: It just goes to show you the layers and layers of stigma that go all the way up through the insurance companies and how much work we still have to do.

Thank you for watching NeurologyLive® Cure Connections®. If you enjoyed the program, please subscribe to our e-newsletter to receive upcoming programs and other great content right in your inbox. Thank you so much.

Current hurdles faced by neurologists when prescribing therapy to treat migraine and advice to help other healthcare professionals as well as patients navigate insurance and access issues. 

Navigating Insurance and Access Issues in Migraine 

We have talked a lot about what we have learned from these new drugs, including the science and research behind them. We have shared our own stories. I wanted to ask you, in this final segment, about patients circling back to each other and self-help groups or blogs. It is a very small world, and migraine is so common, yet when you are in an attack and you are the only person who cannot make the party or go out to dinner, you can feel so alone. Do you think there are certain ways that individual sufferers can connect with each other to learn more by educating through their own journey, as opposed to just patients reaching out to experts in the field?

 I was interested to know, we have talked a lot about patients connecting with specialists, but obviously patients who have been through their own journeys have walked this path. We always say that a smart person learns from somebody else, but a wise person learns from other people’s mistakes as well as their own.

One of the gratifying things about being an advocate is—because I have walked those miles, and I wish I had had someone like me to help me when I was first diagnosed because there was so much trial and error—having a network of support with other people who are going through your same journey or a similar journey. Honestly, some of the friends I have made as a migraine advocate are some of my best friends, and I know that we are going to be friends for life. We help each other, we educate each other, and we pick each other up when we are feeling down. I honestly do not know what my life would be like without my network of other people with migraine.

You have given a huge amount of your own personal time. How do you get the support or the infrastructure to be available to so many people? Do you have any formal funding or support for your network?

I do a lot of volunteer work with different organizations in the migraine space. I am on the board of the National Headache Foundation. I am the Patient Leadership Council chair for that organization. I am on the board of the Alliance for Headache Disorders Advocacy. We do an annual Headache on the Hill Day in Washington DC, and I am also working with CHAMP [Coalition for Headache and Migraine Patients] as a volunteer to help develop materials for students to avoid stigma. It is called migraineatschool.org, and I am really proud of that. I volunteer for Miles for Migraine, an organization that has support groups. Before COVID-19 they had in-person support groups, and now they have Zoom support groups. It is good to know you are not alone because it is such an isolating disease.

Well, I am very relieved to hear that, when you started talking about Miles for Migraine, you were not going to sign Dr Ailani and me up to do an Ironman triathlon with you to raise money for migraine charities. This has been an absolutely fantastic session. Often, with these series and educational materials, the more information we learn, the more questions I have. Certainly, the future seems very bright, and it is really wonderful to hear that research is going on that has brought these medications to the forefront of clinical practice.

One wish of mine would be to try to marry the clinical expertise that you have in the profession with advocates like Jill, because I think that as clinicians, with the best will in the world, we can write a script. We can say “Try this, try that,” and these medications can be very effective, but I think there is a need for multidisciplinary care. It is important to be spending time talking to patients, especially if it is from somebody who has experienced these journeys, these medications, and the quality-of-life effects. We help each other address the big picture and not just write a prescription and say, “Let’s see how this goes.” I thank you so much for your time, and I really look forward to getting feedback through Cure Connections® from people who tune into this segment. This is a wealth of information. Thank you so much, Dr Ailani and Jill, for your wonderful education and really valuable insights.

A patient advocate, Jill Dehlin, RN, explains why patients with migraine should connect with other patients via patient support programs and take a proactive role in managing their condition. 

Migraine Care: The Value Behind a Network of Support 

 Forgive me if I’m putting you on the spot here, but in relation to this newer class of drugs that have only been on the menu in the last few years—if I am a migraine sufferer in the middle of Idaho and I do not want to deal with 5 trains, 2 buses, and a 2-mile walk to go to a specialist hundreds of miles away, what can we realistically expect from a neurologist in our local community hospital? Is it fair to say that we should expect a general neurologist to have a good handle on the roles of these medications and be comfortable prescribing them for a condition that is so common? Or are we expecting too much? Do we need to say to patients who are very debilitated by migraine, “Look, you need to invest in your own health and be prepared to travel farther than your local district to see somebody who has the expertise to help you have a better quality of life for the long term?” How do we balance that for patients?

I think that these medications were designed not only for the general neurologist to use but for most primary care providers to feel comfortable prescribing. A lot of the work that the companies and experts like myself and Jill have done involves outreach and education of other practitioners and clinicians so that they understand these medications and how to prescribe them. If you are in a community without a headache specialist, it is the expectation of your community providers to be able to at least get you started on a regimen, and if that isn’t working, to understand how to get you to the next step. 

That is why there is great programming to keep people up to date with some of these options. If you are stuck in the middle of Idaho, I know an amazing headache expert out there. There are only a couple hundred of us. We are a very small, tight-knit group; we all know each other really well, so when our patients move, we try to move them to our peers so that they stay within the small network.

One of the big themes we have had throughout the Cure Connections® series is how to educate and empower patients and encourage them to be proactive, to take charge of their own health. Hopefully, the series we have done on many different medical conditions have helped patients get the information they need. 

Obviously, we cannot possibly talk about every aspect of migraine and every treatment, but thankfully, the internet has made the world a much smaller place, and we can access people remotely for video consultations. Jill, are there any specific websites or resources that you feel are first-class, evidence-based, easy to understand, and patient friendly that you would recommend to people to become more knowledgeable about the things we have been talking about today?

The National Headache Foundation’s [NHF] website, headaches.org, has a wonderful set of resources for patients. They also have a search feature so people can look for the UCNS [United Council for Neurologic Subspecialties] or the NHF version of certification for nurse practitioners, PAs [physicians’ assistants], non-neurologists, and non-headache specialists. It’s called the Certification of Added Qualification in Headache Medicine, or the AQH. You can take a look there to see where there might be somebody who has an interest in migraine in your area.

There’s another website called headachemigraine.org, and this is an organization called CHAMP [Coalition for Headache and Migraine Patients]. It is a member organization, so myriad different organizations belong to CHAMP. It is like a clearinghouse for people to find resources, and I would recommend headachemigraine.org for people who are looking for different options. It also has some great information to help when you are being stymied by your insurance company. They have template letters that you can send. It is a quite valuable website.

 Thank you for watching NeurologyLive® Cure Connections®. If you enjoyed the program, please subscribe to our e-newsletter to receive upcoming programs and other great content right in your inbox. Thank you so much.

Advice to community neurologists and other care providers who may treat patients with migraine in the community setting on incorporating newer therapies, such as CGRP inhibitors, into practice, and a list of reputable resources where patients can turn for additional support. 

Treating Migraine in the Community Setting 

Jill, I want to move on and talk about the phenomenal value that you bring to the table in migraine advocacy. As a doctor in medicine and as a sufferer of migraines, I thought I knew a lot, but we never stop learning in medicine. Even people like Dr Ailani, who are at the forefront of the field and dealing with this all day, every day, who are keeping very up to date with all these new medicines, are still learning. 

Can you talk a little about your work in patient advocacy and how you communicate your wealth of knowledge and expertise personally and professionally? How do you get the word out to people watching segments like this, wanting to get the right information—the relevant information, the up-to-date, not just Dr Google, information? How do you maximize getting the word out to the right people at the right time?

I think Dr Ailani would agree with me in that you have to start with where people are. Some people have educated themselves somewhat about their disease. That is great because you can start giving them information at a little higher level. But there are others who are just figuring out that they do not have a sinus headache, and that their physician has not been treating them for migraine. They have been getting some other treatment for something that they do not have.

I also direct people to different kinds of organizations and websites that have reputable information. There are a lot of blogs out there that have great information and some that do not have such great information; a discerning consumer needs to be able to take a look at what these blogs are saying and figure out if that is reliable or not. One thing they can do is see if the statement that is given on the website is cited in some way and then look up that article. You can compare what that person is saying on their blog to what the article is really saying. Not a lot of people are going to do that, so they trust the information they are given on blogs. There are some blogs that have much better information than others, and you have to be so careful about that.

What do you consider the main role of an advocate? What do you do best, do you think? Do you think it is helping people connect with the right clinicians? Is it providing empathy for people who may feel very alone and isolated in this? Is it helping them consider new treatment options? How do you rate what you offer? How do you determine your most valuable roles when being an advocate?

One of the things I do is help people understand their disease. I will educate them about what is happening, but as Dr Ailani does, I will listen to their story because I do not want to be sending them down some rabbit hole that is not applicable to them. I try to tell people that they can demand more from their treatment. So often people try to muddle through with over-the-counter medications and are in complete migraine denial. Then they set themselves up for a rebound headache or even run the risk of going from being an episodic to chronic migraine sufferer. You have to discern what kind of information they need. 

I do not often tell people about headache specialists that they can see because insurance plans are so different and the geographic limitations are so severe. I will help people figure out ways to get past all the insurance denials. These insurance companies will often put up these huge barriers because they do not want to pay for these expensive, new medications. They want to go through the whole algorithm and include β-blockers, triptans, and topiramate to make sure those cheaper versions do not work, but sometimes you are just wasting time if you are having bad adverse effects from those drugs, and you start to feel like a guinea pig if nothing is working.

Well, for patients, when they are working with a neurologist—a neurologist is a specialist, but we all know that even within a subspecialty, there are special interests. One neurologist may have a very strong interest in migraine; another may have an interest in seizure disorders or multiple sclerosis. Dr Ailani, you must see many patients who have seen other neurologists who may not necessarily have interest and expertise in migraine. As a patient, you may not know what your doctor’s subspecialty or interest is. Migraines are so common, but even migraine specialists can only see so many patients per day. How do we guide patients who are listening to this segment to see the right specialist?

 I think, in the end, it is not about finding the right specialist, but the right person. The right person is the one who is willing to work with you and with whom you feel comfortable building a relationship. I think the worst thing—there are 2 things you can do that are the worst. I think Jill mentioned the first, which is to accept that nothing is going to change. I think that is the worst thing I see: someone will be willing to accept nothing happening for a long time because they think that is the best there is. I see it often.

The second thing is giving up too quickly when someone is really trying to help you, or when you go from person to person and you do not build that relationship with a clinician, especially when living with a disease like migraine. It can take time and effort, and it sometimes is a process of trying, combining, and shifting treatment plans. There is creativity—add a little of this, add a little of that. I think this world is very fast-moving and fast-paced. Patients often want to hear everything at once, but you cannot process all of that at once, so we have to give it in pieces. I think patients should try to build a relationship but understand when it is not going to be a buildable relationship. That relationship can be with your primary care physician. It can be with a general neurologist. It can be with your gynecologist. It just has to be with a person you trust, who is willing to work with you.

Jill Dehlin, RN, describes her role as an advocate in supporting others with migraine and connecting them to the support and resources needed to best manage their condition. 

Migraine Advocacy  

“When I’m thinking about a patient who has maybe failed an oral triptan, who has failed their standard of care, this is when I might think about DHE. Somebody who has a longer attack or someone who is known to delay treatment.”

The success of intranasal dihydroergotamine (DHE) administered via a novel precision olfactory delivery (POD) system, known as INP104, in the STOP 301 trial (NCT03557333) has been an example of an effective nonoral approach to migraine care. As many of the migraine therapies available are currently either infusion or oral treatments, the introduction of intranasal administration has opened a window for more variety for patients.

Intranasal delivery is particularly promising in the case of patients who experience nausea from their migraines—one of the more common most bothersome symptoms reported by patients. In these instances, according to migraine specialist Jessica Ailani, nasal therapies are an excellent option to offer individuals. Additionally, some of these nonoral therapies have a more rapid onset of action, allowing for a quicker response to treatment. When it comes to DHE, a therapy that does not offer an oral formulation, she noted, this intranasal route is particularly helpful for patients who are known to delay their treatment due to long-lasting attacks.

2021 American Academy of Neurology (AAN) Annual Meeting

, April 17-22, Ailani gave a talk in an industry update session that covered some of the ongoing conversations about the use of nonoral medications for migraine. Ailani, the director of the MedStar Georgetown Headache Center and associate professor of neurology at MedStar Georgetown University Hospital, shared with 

 her takeaways from the STOP 301 data, as well as when she thinks about taking nonoral approaches for her patients and what advantages that they can offer due to the ongoing interactions between gut health and the brain.

The director of the MedStar Georgetown Headache Center spoke to the considerations she makes in determining when patients with migraine may need a nonoral therapy to address their disease.

Assessing When to Take a Nonoral Approach to Migraine: Jessica Ailani, MD

“We already know that DHE is very effective for migraine. It’s really considered the gold standard, especially for those who have what we call status migrainosus—you’re having a migraine attack that’s lasting greater than 36 hours and you’re really in trouble. That might be a reason to go to the emergency room seeking care, and this is really how DHE was initially studied.”

, April 17-22, featured an industry update session that covered some of the ongoing conversations about the use of nonoral medications for migraine, and the role that the interaction between the brain and the gut plays in the headache disorder. Part of this session covered the recently completed STOP 301 trial (NCT03557333) of a nasally delivered investigational migraine treatment, INP104, which is a reformulation of dihydroergotamine (DHE) administered via a novel precision olfactory delivery (POD) system.

To find out more about how this therapy has performed in its clinical development and what the STOP 301 trial revealed about its efficacy and safety, 

 spoke with Jessica Ailani, MD, director, MedStar Georgetown Headache Center, and associate professor of neurology, MedStar Georgetown University Hospital. In the conversation, she detailed the data from the trial and what her main takeaways were.

Specifically, she shared some of the unique approaches from this trial, and some clinical pearls about the use of DHE for patients with migraine and its history as an effective, but often difficult to obtain treatment. Ailani also discussed how DHE evolved over the years into this new formulation.

The director of the MedStar Georgetown Headache Center spoke to the efficacy and application of a new formulation of the longstanding agent dihydroergotamine in the treatment of migraine.