Dr Jessica AilaniJessica Ailani, MD
Recent study findings have revealed that despite contradicting recommendations from the American Headache Society and other organizations, a high rate of patients with migraine are still being prescribed opioids for acute relief. Adding to that troubling news, migraine specialists have been faced with a pair of major challenges in migraine care: the education barrier and the treatment gap.

The barrier lies in the lack of diagnostic and treatment understanding on the clinician side, and the simple knowledge of the diagnosis itself among patients—many of whom it appears do not know migraine is a diagnosable disease. The gap, meanwhile, divides the available treatments for migraine from the lack the specificity and detailed understanding that migraine specialists require to treat this patient population.

To find out more about these challenges and how they are currently being addressed by physicians, NeurologyLive sat with Jessica Ailani, MD, director, MedStar Georgetown Headache Center, and associate professor, neurology, MedStar Georgetown University Hospital, at the 2019 American Headache Society (AHS) Annual Meeting, July 11-14, in Philadelphia, Pennsylvania. Ailani shared her insight into ongoing efforts in drug development, what the ideal future may hold for migraine medicine, and just how far off the field is from getting there.

NeurologyLive: What did the CaMEO study data ultimately tell physicians about patients with migraine?

Jessica Ailani, MD: The CaMEO trials, which are epidemiology trials that are looking at what are patients doing and how is migraine affected their life, but also prescription patterns. There is a lot of data out there that shows that it's a struggle to get the diagnosis of migraine, but once you get the diagnosis and you're given a prescription, what happens then?

It's very interesting to me that many of our patients might fill a triptan, but that they don't refill the triptan. If they don't refill the triptan, then what happens to them? We know that triptans are, primarily, coming from primary care providers—they're the biggest prescriber group out of other medical groups, and it makes sense, they're the largest group of medical providers out of all the general specialties that you have.

So, it goes back to not only what the patients are feeling but what is the providers going to next, and it seems that it's possible that if they're not working or they're not filling their prescription, that maybe primary care providers are then starting to write medications for opioids or butalbital-containing compounds because they want the patients to feel better. There's a lack of education that maybe that's really not the best next step, that maybe it's something else that they should be trying. This is a huge area of unmet need. We know that, in this country, we're facing this huge opioid epidemic. We know that opioids and butalbital are not good treatments for migraine in that we can actually worsen the underlying disease by using these types of medication. There's an area where you have the patients and you have the clinicians feeling like they have something, but maybe they don't like it because there are adverse effects, or it's not as effective as the patient was hoping for and we're not sure what else to go to. This is where that gap is for new acute treatments to come in and be something that patients tolerate well, that they can try if they failed a triptan, and that having more than 1 other option might help push that prescription rate for opioids down.

How does this gap in available treatments impact clinical care for migraine and what is being done?

There's both a barrier and a gap. The gap is that we don't have enough treatment options that are well-tolerated, that are safe, that we can provide to an aging population—a population with multiple comorbidities where we'd worry about which medications we're putting them on. But, we also have the barrier of education of does the clinician understand how to diagnose and treat migraine, does the patient understand that they have a disease and they have a disease that has a diagnosis and has treatment options that are available to them? It's a two-part thing.

We are working so hard on trying to increase education, and having new options is going to be supremely helpful because there are more people in the marketplace, there's more advertising, there's more consumer information—which drives more patients to come and talk to their providers about, “Hey, I heard about this new drug,” and maybe “I don't want that drug, but tell me a little bit more about what it is.” We see that all the time in the clinic, patients coming in who are really well managed but have been seeing advertisements or have heard something on social media and they just want to know what's going on in this world. It seems like there's some real excitement and they're really happy to hear that.

Has the recent influx of new medicines helped to address this therapy gap? If not, what still needs to happen?

I don't know if that's enough. I think that we could probably create another 15 to 20 drugs, and then, maybe, we'll start to feel like we have enough tools to manage. Migraine is such a complex disease that just it's not a one-size fit for every patient, so having numerous molecules available to us is really important. I would hope that's where we're going to end up going. Not necessarily the person with the disease but, here's the disease that presents with high-frequency episodic migraine very quickly developing into chronic, here's the disease that stays rare and episodic and always stays rare and episodic—how do these diseases respond? How do these representations of a single disease respond differently to 2 different types of treatments?

Another way to look at it is to have 2 patients who have a similar type of presentation of their disease, but yet they're responding differently to treatments. How do we get it so that we have enough of these options that if they're not responding to this targeted pathophysiology, we know that there's this backup pathophysiology and a third backup?

Once we get enough treatment plans that are targeting specific pathophysiology, can we then start to focus on what does that presentation of disease look like and can we then start to separate it before we start experimenting? Not, “Try this, try that, try this,” but, “Hey, I hear you have a lot of nausea. For our patients that have a lot of nausea, this medicine seems to work the best.”

That would be an amazing place to end up. I don't think we're close to that because I actually don't think we have enough tools yet to really start to develop that kind of specialization. But I think that's what our patients really want and that's what we want as clinicians as well. We don't want to struggle with, “I'm not sure, I'm going to guess that this might work,” because the more failure you have, the less hope the patient has and the more you have work to do to explain not to give up because there are these other options. We're trying to figure out what this disease is in one case versus someone else.

Transcript edited for clarity. For more coverage of AHS 2019, click here.
REFERENCE
Litpon R. Depression and Anxiety Are Associated with Increased Headache-Related Disability in Episodic and Chronic Migraine: Results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study. Presented at: 2019 American Headache Society Annual Meeting. July 11-14, 2019; Philadelphia, PA. Poster P160.