Getting a head start on Migraine Prevention

Migraine prevention is important to patients and clinicians. A recent Consensus Statement on treatment goals for migraine prevention, initiating preventive therapies in the acute attack, and patient-based assessment of treatment efficacy were all discussed at this AAN Virtual 2022 Industry Update session.

Why is prevention important?

Professor Dawn Buse (Albert Einstein College of Medicine, New York, USA) began by explaining how inadequate treatment of migraines may have long-term implications on pathophysiology and clinical symptoms and outcomes1,2. This can result in:

Inadequate treatment of migraines may have long-term implications on pathophysiology and clinical outcomes

  • Worsening of migraine frequency1
  • Increased severity of symptoms2,3
  • Increased acute medication use and reduced overall effectiveness of medications4,5
  • Increases in disability and comorbidities, and decreased health-related quality of life6

Increased disease severity may correlate with structural brain alterations7, and alterations in neuropeptide levels8 and neuronal activation and function9.

One study of the relative importance to patients of different outcomes from a potential new treatment showed that, after ‘take away the headache’, factors weighted most highly were preventive goals of ‘prevent the attack from carrying through’ and ‘make sure no other attack follows’10.

 

What should be considered?

Intervening early to prevent or reduce long-term consequences is an important component of effective migraine management

Intervening early to prevent or reduce long-term consequences is therefore an important component of effective migraine management explained Prof Buse. This should be individualized to the particular patient, if possible, as each will come with their own specific migraine and medical history.

Comorbidities are common, with anxiety, depression, chronic pain, arthritis, hypertension, hypercholesterolaemia, and allergies each reported by over a third of patients with migraine11. Comorbidities may be important in the transition from episodic to chronic migraine12, as is medication overuse headache12.

 

What are the goals?

The AHS put together a Consensus Statement in 202113 listing key overall treatment goals to be considered in migraine prevention, including:

  • Reduce attack frequency, severity, duration, and severity
  • Reduce reliance on poorly tolerated, ineffective, or unwanted acute treatment
  • Enable patients to manage their disease to enhance a sense of personal control

There is a continuing need to bridge the gap between healthcare professionals’ goals and the patient’s needs, as they may differ14.

 

What treatments are available?

Prevention of migraine attacks requires a personalized long-term multi-pronged approach. This should include non-pharmacological, lifestyle and educational components as well as pharmacological agents. The AHS Consensus Statement13 offers a helpful algorithm to aid discussions with patients. Preventive drug treatment can be considered or offered depending on number of headache days/month and degree of associated disability.

Prevention of migraine attacks requires a personalized long-term multi-pronged approach

Dr Jessica Ailani (Georgetown University, Washington DC, USA) and Dr Paul Winner (Nova Southeastern University, Ft. Lauderdale, USA) discussed results from recent clinical trials using CGRP-targeted therapies in migraine prevention15, including benefits of initiating preventive treatment during the acute attack16.

 

How is success measured?

Patient involvement allows specific goal-setting using patient-based assessments of headache impact

Prof Buse described how ‘treat to target’ is an important concept in any migraine prevention plan. Patient involvement in all decision making allows specific goal-setting using patient-based assessments of headache impact17. Targets are then assessed frequently by both patient and clinician to monitor progress, and treatments regularly adjusted if the target is not reached. This ensures that the individual patient’s self-report of the presence, severity, frequency, and impact of their headache is the basis for assessing the effectiveness of any therapeutic intervention17.

Educational financial support for this Satellite symposium was provided by Lundbeck.

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References
  1. Bigal M, Lipton R. Migraine chronification. Curr Neurol Neurosci Rep 2011;11:139-48.
  2. Charles A. The pathophysiology of migraine: implications for clinical management. Lancet Neurol 2018;17(2):174-82.
  3. Bigal M, Ashina S, Burstein R, et al. Prevalence and characteristics of allodynia in headache sufferers: a population study. Neurology 2008;70:1525-33.
  4. Negro A, Curto M, Lionetto L, et al. A critical evaluation on MOH current treatments. Curr Ther Options Neurol 2017;19:32.
  5. Diener H-C, Limmroth V. Medication-overuse headache: a worldwide problem. Lancet Neurol 2004;3:475-83.
  6. Buse DC, Reed ML, Fanning KM, et al. Demographics, headache features, and comorbidity profiles in relation to headache frequency in people with migraine: results of the American Migraine Prevalence and Prevention Study (AMPP) Study. Headache 2020;60:2340-56.
  7. Kim J, Suh S, Seol H, et al. Regional grey matter changes in patients with migraine: a voxel-based morphometry study. Cephalalgia 2008;28:598-604.
  8. Tajti J, Szok D, Majláth Z, et al. Migraine and neuropeptides. Neuropeptides 2015;52:19-30.
  9. Russo A, Tessitore A, Esposito F,  et al. Pain processing in patients with migraine: an event-related fMRI study during trigeminal nociceptive stimulation. J Neurol 2012;259:1903-12.
  10. Smelt A, Louter M, Kies D. What do patients consider to be the most important outcomes for effectiveness studies on migraine treatment? Results of a Delphi study. PLoS One 2014;9(6):e98933.
  11. Buse DC, Manack A, Serrano D, et al. Sociodemographic and comorbidity profiles of chronic migraine and episodic migraine sufferers. J Neurol Neurosurg Psychiatry 2010;81(4):428-32.
  12. Buse DC, Greisman JD, Baigi K, et al. Migraine Progression: A Systematic Review. Headache 2019; 59 (3): 306-38.
  13. Ailani J, Burch RC, Robbins MS. The American Headache Society Consensus Statement: update on integrating new migraine treatments into clinical practice. Headache 2021;61:1021-39.
  14. Peres MF, Silberstein S, Moreira F, et al. Patients’ preference for migraine preventive therapy. Headache 2007; 47: 540-5.
  15. Silberstein S, Diamond M, Hindiyeh N, et al. Eptinezumab for the prevention of chronic migraine: efficacy and safety through 24 weeks of treatment in the phase 3 PROMISE-2 study. J Headache Pain 2020;21 (1): 120.
  16. Winner P, McAllister P, Chakhava G, et al. Effects of intravenous eptinezumab vs placebo on headache pain and most bothersome symptom when initiated during a migraine attack. A randomized clinical trial. JAMA 2021;325(23):2348-56.
  17. Haywood K, Mars T, Potter R, et al. Assessing the impact of headaches and the outcomes of treatment: a systematic review of patient-reported outcome measures (PROMs). Cephalalgia 2018;38(7):1374-86.
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