8 Approaches to Integrating New Migraine Treatments Into Clinical Practice

January 11, 2019

A review of existing guidelines and principles for treating migraine released by the American Headache Society.

The American Headache Society (AHS) has released a consensus statement about new treatments for the prevention and acute treatment of migraine in clinical practice.¹ The statement was developed with input from various stakeholders, including industry representatives and patients and their advocates, as well as experts from North American and Europe. It includes a review of existing guidelines and principles for treating migraine, as well as the results of recent clinical trials. These approaches may be helpful for patients who prefer nondrug therapy, or with poor response or contraindications/intolerance to medication. They may also be helpful for patients with high stress levels, pregnant or lactating women, and patients with medication overuse.

According to the statement, indications for preventive therapy are unchanged. These are based on headache frequency and amount of disability and include: migraine that significantly interferes with daily activities, frequent attacks of ≥4 headache days/month, contraindication/failure/overuse of acute therapy, adverse events to acute treatment, preference for preventive therapy, and/or certain types of migraine (eg,. migraine with prolonged aura). The statement also lists modified criteria for identifying patients for preventive therapy.

General principles for using oral preventive treatments for migraine include using evidence-based treatments, starting at a low dose and titrating slowly to reach a therapeutic dose if possible, allowing for an adequate trial duration of at least 8 weeks, maximizing adherence, and establishing realistic treatment expectations. While many patients may experience only partial response, some may experience additional benefits with continued use over 6-12 months.

The AHS considers the following oral treatments to have established efficacy for prevention of migraine: antiepileptic drugs, beta-blockers and frovatriptan (for short-term preventive treatment of menstrual migraine). Women of childbearing potential who are not on reliable birth control should not take valproate sodium or topiramate, due to the risk of birth defects. The following drugs are probably effective in migraine prevention: certain antidepressants, beta-blockers, and angiotensin receptor blockers.

Advantages of newer injectable treatments include a faster mechanism of action without the need for titration. The consensus statement describes ways to determine meaningful response to therapy, which can help guide clinical decision making. It also offers an algorithm for starting therapy with CGRP inhibitors, as well as criteria for continued treatment with them using validated, migraine specific patient reported outcome measures. Because some patients may have delayed response to CGRP inhibitors, the AHS, recommends assessing response to these medications every three months with monthly injectables, and every six months with quarterly injectables.

General principles for acute treatment of migraine include using evidence-based treatments, treating attacks early, using non-oral medications for certain patients (eg, severe vomiting), addressing tolerability and safety issues (eg, triptans and ergotamines in CAD), using self-administered rescue treatments for appropriate patients (eg, history of severe attacks), and avoiding medication overuse. Strategies for avoiding medication overuse include adjusting dosage/therapy in cases of inadequate response, limiting treatment to about two headache days per week and/or offering preventive treatment when indicated.

The AHS considers the following treatments to have established efficacy in acute migraine: triptans, ergotamine derivatives, NSAIDs, opioids (not recommended), and combination medications. The following drugs are probably effective: ergotamines and other forms of DHE, certain IV and IM NSAIDs, IV magnesium, isometheptene-containing compounds, and combinations of codeine/acetaminophen or tramadol/acetaminophen. Antiemetics may also be considered.

The AHS considers certain neuromodulatory therapies to be appropriate for the prevention and acute treatment of migraine. FDA-approved neuromodulatory devices include: single-pulse transcranial magnetic stimulation (acute and preventive therapy), electrical trigeminal nerve stimulation (acute and preventive therapy), and noninvasive vagus nerve stimulation (acute treatment).

Biobehavioral therapies should also be considered and include education and lifestyle modification, including minimizing exposure to triggers. Techniques with Grade A evidence for effectiveness in the acute and preventive treatment of migraine include: CBT, biofeedback and relaxation therapy. Combining biobehavioral therapies with medications has more benefits than either alone.

Reference

1. American Headache Society. The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. Headache. 2019;59:1-18.