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Expert Perspectives on the Interdisciplinary Management of Migraine - Episode 12

Balancing Multiple Migraine Treatment Options

A migraine specialist cautions against going through migraine treatments quickly and not utilizing their full potential.

Kita Williams, MD: Although it’s advantageous to have multiple therapeutic options for managing and treating migraines—and I’ll talk about those advantages—there are also some disadvantages. First, to discuss the advantages, it’s a great that we have so many migraine-specific medications. We have a lot to choose from. The disadvantage, however, is that it can cause clinicians to be…less patient with the medication. What I mean is that at 1 time we would say, “Let’s try cutting the dose in half. Let’s see if you still have these same adverse effects. Let’s see what we can pair with it, and maybe it will carry you through a bit longer.” But now, because we have so many medicines, we’re quicker to say, “That was a failure. Let’s go to something else.”

There’s a particular CGRP antagonist that, when injected, works extremely well. After a couple of weeks, the patients are saying, “It worked the first 2 weeks, but now I’m waiting 2 weeks, and I’m in pain again, and I can’t take it again until I’m a month out.” If we didn’t have a lot of choices, we tend to say to inject it. It works for a good 2 weeks. For the following 2 weeks, while you’re waiting for your next injection, let me give you this medicine to bridge the gap. You inject, and you’re going to take this medication to bridge the gap when you have your migraines for the next 2 weeks. At the start of the month, you can inject again. We’re not doing that as much, and we need to get back to those ways of thinking through issues.

Another example is 1 of the gepants can cause drowsiness. A patient will take it in the morning and say, “I couldn’t function because I had drowsiness and was so fatigued,” as opposed to saying, “Let’s switch to another 1.” Often we must take a step back and say, “How about taking that at nighttime?” Let’s see how that works. Or how about cutting the dose in half and seeing if they still have the migraine control but not the drowsiness. Having too much of a good thing or too many options can have what I call the Christmas Day effect. Kids will get a present and play with it for a little while, and they’ll toss it and open the next 1. We’re having fun, having these medicines at our disposal, and we’re quick to toss them and go to the next 1. That’s the disadvantage of having so many modalities and treatment options at our disposal.

Transcript Edited for Clarity