Optimal Management of Acute and Preventive Migraine - Episode 6

Approaching the Treatment of Migraine

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Sait Ashina, MD, and Jessica Ailani, MD, comment on the importance of individualized treatment regimens for the management of migraine.

Jessica Ailani, MD: We're going to be talking about the management of migraine, probably one of the most interesting and exciting parts of our field. Not only do we get to diagnose and be there with our patients through their lifespan, but we get to engage in conversations with them about all the different therapeutic options that we have to offer them to improve the quality of their life. We are going to start this conversation by talking about how we can individualize plans for the patient that's sitting in front of us, and I thought, Sait, maybe you can talk to us about why it is so important for the migraine patient to have an individualized plan.

Sait Ashina, MD: I want to go back to what we already said about the burden and the impact the migraine has in an individual. And that brings us to this level that we need to help patients; we need to treat them. And unfortunately, the reason ethological data show that migraine patients remain undertreated and underdiagnosed, but undertreated as well, despite availability of effective treatments. Why do we need to treat the patients? Why do we need to help them? One of the major reasons is to give them pain relief. Are they able to go back to their lives, to their families, to have the ability to function in every day life. And those are the main factors that we looked at. But in addition, we want to prevent patients to progress to have more chronic headaches, which again, in turn, can cause the burden. Now the goals of acute treatment would be to give the rapid and consistent freedom from pain and associated symptoms to relieve the most bothersome symptoms. For example, photophobia in some patients is a very bothersome symptom; in some people, it could be nausea, prevent a recurrence of the migraine attacks with the acute treatment, the ability to function, restore movement of that, and then we're thinking of the minimal or less severe adverse events. When we choose, with our choices are based on the drugs that can help the patient but at the same time, they don't cause adverse effects. And another important thing is the financial considerations, the cost of the medications. For the preventive treatments, the goal is to decrease the headache frequency by at least 50% or more. Again, improve the ability to function as well as prevent patients from having another attack. And here we also talk about, for example, there are certain subgroups of migraine such as hemiplegic migraine or frequent auras for those preventative treatments are needed for those patients. The risk of acute analgesic overuse with the patients are at risk of that. Then there is also indications for preventative treatment.

Jessica Ailani, MD: What I hear you saying is that we have to look at the characteristics of the type of migraine the patient is having. Do they have aura? Which can come with high burden for some patients? Do they have nausea? Are they really disabled? Perhaps they need prevention. If they have a lot of associated symptoms like nausea, perhaps they need a non-oral acute treatment. Really focusing in on patient-specific symptoms to try to individualize the treatment plan. And not everybody gets the same treatment. This is extremely frustrating to patients. I know in my waiting room; the patients will talk to each other. And then they'll come to the back and say, "Dr Ailani, why is your other patient on this treatment, and I'm on this treatment? How come we're not on the same thing?". And I always tell them, "Did you want me to treat all of you like you're the same person?". And this always gets them, they're like, "No". You are all individuals. "Yes". And all your migraines are different. "Yes, yes". And that usually settles them right down. But it's extremely important that our patients also understand that we are talking about treatment options. We're finally in a generation period where we have so many options to offer them that we can start individualizing treatment plans.

Transcript Edited for Clarity