The Migraine Patient Journey: Episodic Migraine and CGRP Inhibitors - Episode 12

Selecting Treatment to Manage Migraine

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Variables that neurologists and other healthcare professionals need to consider when selecting an appropriate prescription therapy for migraine, and recommendations by a patient advocate on staying adherent to therapy and predicting attacks.

Philippa Cheetham, MD: Obviously, there are potential contraindications or interactions with other medications, and of course, we know that patients are on different medications. Certainly, things like the calcium channel blockers and the β-blockers, need careful consideration, especially for cardiac patients with other medications that they may be on for their cardiovascular system. For patients who are coming to you who are not on any regular medication, do you have a first-line approach in your mind that you would start with, or is that very much based on the signals in the patient’s history? What may make you choose an anticonvulsant over a β–blocker, or a calcium channel blocker over an antidepressant-type medication?

Jessica Ailani, MD: Usually I listen to the patient’s history and find out if there are other comorbid factors that we are trying to cotreat, like hypertension or depression. In a patient who has no other comorbid condition, where do we start? In that case, I look at FDA approval and the best evidence. Usually, the best evidence will bring me to very few options, and then I will discuss those best evidence options with the patient, keeping their insurance preference in mind because cost is extremely important. We must look at what is going to be cost friendly.

If a patient has never been on any medicine before, and has no comorbid conditions, we discuss best evidence. We may say, we have topiramate, and we have propranolol, which is a β-blocker, and these are some of our best evidence, FDA-approved medications. Then we have our newer category medications, the CGRP [calcitonin gene-related peptide] monoclonal antibodies for migraine prevention, which come with fewer adverse effects but aren’t usually offered as a first-line option. They are not generic, so that is always a problem with insurance.

They are newer, and so that can be problematic in that we do not know about the long-term, 10 year or 20-year safety and adverse effects. If a young, child-bearing woman is seeing me, those medications do have to be stopped for a period before they start trying for pregnancy. The same is true for topiramate and for propranolol as well, but usually we can stop those medicines 2 weeks before they start trying for pregnancy. There are a lot of factors that go into choosing a medicine, but it is all discussed with the patient, so they have a good understanding about their options, and we whittle it down to 2 or 3 so it’s a bite size consideration. Then I can say, “Out of the 2 or 3, this is what I would suggest we consider because of your case. But if you don’t like that, let’s talk about what else we have to offer.”

Philippa Cheetham, MD: Of course, Jill, we all know that, even for people with regular migraines, the frequency of migraines can be very unpredictable. We have talked about some of the obvious triggers, but there certainly can be days when you think you have done everything perfectly—you are eating the right food, you have had the right amount of sleep, you have exercised well, you are hydrated, and then bang! If you are taking a medication and these migraines are debilitating when they come, how do you say, well, this medication has failed? How do we say, “OK, well, you have just had a bad one, but you’ve just started this medication?” Or “OK, you’ve been on this medication for a month, it was only one bad attack.” How do you define failure for something that is so sporadic and unpredictable? We know with blood pressure medication, you take a pill and your blood pressure either goes down or it does not, but with migraine it is not so simple as that, is it?

Jill Dehlin, RN: I am so glad you asked this question because this is such an important point. People need to keep a migraine diary, a journal of when they are experiencing head pain, whether it is a migraine or not. By looking at your journal, you can almost predict, for future months, what those triggers might be. You can keep track of food that you ate beforehand, or the weather, or some other trigger that you were exposed to, and then the medicine that you were taking, the acute medicine you were taking, and how long it took to start working for you. A big problem for people with migraine is that initially they are not certain if taking a triptan would be worth it, if that headache is migraine worthy. Is it just a headache or is it a migraine? The other issue is that people with migraine are not prescribed mass quantities of triptans to take whenever we want, for many reasons. So, people start to decide whether they should take it, or they will save their triptans to use before an important event. That starts a bad cycle too when people are not treating their migraines with intention.

Philippa Cheetham, MD: 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.

Transcript Edited for Clarity