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Migraine Management

Much like medical diagnosis, effective migraine management can present a challenge for physicians and patients. Find AHS guidelines for initiating acute and/or preventive treatments and improving patient outcomes

Acute and Preventive Treatments

Migraine can be treated with acute and preventive treatment.1,2 These two strategies for treating migraine have distinct but complementary treatment goals.2,3

Overview of acute and preventive migraine treatments

Patients with migraine who have frequent and/or severe attacks may require both acute and preventive treatment approaches.1,2

A number of drug classes used in the acute and/or preventive management of migraine:3

Treatment classes for acute and/or preventive
migraine therapy
Treatment classes for acute and/or preventive migraine treatments Treatment classes for acute and/or reventive migraine treatments

AHS Treatment Recommendations

The American Headache Society (AHS) provides evidence-based recommendations for the initiation of acute and preventive treatments.3

AHS Recommendations for Acute Treatment

According to AHS guidelines, all patients with a confirmed diagnosis of migraine should be offered a trial of acute pharmacologic and/or nonpharmacologic treatment.3

Goals of acute treatment include achieving rapid freedom from pain and associated symptoms and restored ability to function.3

Considerations for acute treatment include those related to efficacy, safety, tolerability, comorbidities, and concomitant medications.1,3

Migraine-specific and general pain medications are recommended for the acute treatment of migraine.1-3 Specifically, the AHS recommends the use of NSAIDs, nonopioid analgesics, or combination therapy for mild-to-moderate attacks and migraine-specific agents for moderate or severe attacks and mild-to-moderate attacks that respond poorly to nonspecific therapy.3

AHS-listed drugs for acute treatment of migraine with established efficacy3

General pain medications

  • NSAIDs
  • Combination analgesics

Acute migraine-specific medications

  • Triptans
  • Ergotamine derivatives

Recently approved acute treatments

  • Gepants
  • Ditans

Regardless of which acute treatment is prescribed, patients should be instructed to treat at the first sign of pain to improve the probability of achieving freedom from pain and reduce attack-related disability.3

AHS Recommendations for Preventive Treatment

Preventive treatments—pharmacologic, interventional, biobehavioral, neurostimulation, nutraceuticals, and lifestyle modification—are important parts of the overall approach for a proportion of people with migraine, and multiple evidence-based guidelines are available.3 However, epidemiology data support that preventive treatment is underutilized, as only about one-third of patients with migraine who qualify for preventive treatment receive it.9,10

Preventive treatment is recommended for patients with elevated headache frequency, increased symptom severity, and/or impaired functioning.3

Identifying Patients for Preventive Treatment

Patients are often selected for preventive treatment based on attack frequency and degree of disability. Consensus guidelines identify groups of patients in whom preventive treatment should be offered or considered, based on these parameters.3

AHS guidelines for identifying patients for preventive migraine treatment AHS guidelines for identifying patients for preventive migraine treatment

AHS Criteria for Preventive Treatment

Preventive pharmacologic treatments should be considered for patients with migraine in any of the following situations:3

  • Attacks significantly interfere with patients’ daily routines despite acute treatment
  • Frequent attacks (≥ 4 MHDs)
  • Contraindication to, failure, or overuse of acute treatment
  • Adverse events with acute treatment
  • Patient preference

TEST YOUR KNOWLEDGE

In 2021, the AHS suggested patients should be considered for preventive treatments based on which of the following factors? Select all that apply.

A Attacks significantly interfere with patients’ daily routines despite acute treatment

B Frequent attacks

C Contraindication to, failure of, or overuse of acute treatment

D Adverse events with acute treatment

E Patient preference

Correct

Incorrect
Correct answer: A, B, C, D, E

AHS, American Headache Society.

AHS Recommendations for Initiating Treatment With CGRP mAbs

Initial treatment prescribed by a clinician when a patient is aged ≥ 18 years and 1 of the following is met:3

4-7 monthly migraine days* and both:

  • Inability to tolerate (due to side effects), or inadequate response to, 8-week trial (at a dose established to be potentially effective) of two prior treatment classes†

  • At least moderate disability (MIDAS ≥ 11, HIT-6TM > 50)

8-14 monthly migraine days* and:

  • Inability to tolerate (due to side effects), or inadequate response to, 8-week trial of two prior treatment classes†

Chronic migraine and either:

  • Inability to tolerate (due to side effects), or inadequate response to, 8-week trial of two prior treatment classes†

  • Inability to tolerate, or inadequate response to, a minimum of two quarterly injections (6 months) of onabotulinumtoxinA

*International Classification of Headache Disorders, third edition (ICHD-3) migraine with or without aura.

† ≥ 2 of the following: (1) anticonvulsants, (2) antiepileptics (not for use in women of childbearing potential who lack an appropriate method of birth control), (3) β-blockers, (4) tricyclic antidepressants, (5) serotonin-norepinephrine reuptake inhibitors, (6) other level A or B treatment classes (established efficacy or probably effective) according to American Academy of Neurology (AAN) scheme for classification of evidence.

Explore the role of CGRP signaling in migraine pathophysiology

AHS Criteria for Continuation of mAbs to CGRP or Its Receptor or Neuromodulation Therapy

Criteria for continuation of mAbs to CGRP or its receptor or neuromodulation therapy3,*
Reauthorization after initial use† is approved when EITHER of the following criteria are met:

Reduction in mean monthly headache days or headache days of at least moderate severity of ≥ 50% relative to the pretreatment baseline (Diary documentation or medical professional attestation)

A clinically meaningful improvement in ANY of the following validated migraine-specific patient-reported outcome measures:

MIDAS

  •    i. Reduction of ≥ 5 points when baseline score is 11-20
  •    ii. Reduction of ≥ 30% when baseline scores > 20

MPFID

  •    i. Reduction of ≥ 5 points

HIT-6

  •    i. Reduction of ≥ 5 points

*Exceptions to these criteria may be made under circumstances when deemed medically indicated by the prescribing licensed licensed clinician.

†Initial authorization: 3 months for treatments administered monthly; for treatments delivered quarterly (every 3 months), 2 cycles of treatment (6 months).

 
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Use an Interactive Migraine Disability Calculator to see score calculations for patients with migraine

TEST YOUR KNOWLEDGE

According to the 2021 AHS guidance, which of the following criteria should factor in to the decision to initiate preventive treatment for migraine with a mAb targeting the CGRP pathway? Select all that apply.

A Inadequate response to an 8-week trial of ≥ 2 other preventive migraine treatments included in the AAN scheme for classification of evidence

B Migraine day frequency

C Inability to tolerate or inadequate response to ≥ 2 quarterly injections (6 months) of indicated neurotoxin therapy (onabotulinumtoxinA) for patients with chronic migraine

D Inability to tolerate (due to side effects) ≥ 2 other preventive migraine treatments included in the AAN scheme for classification of evidence

Correct

Incorrect
Correct answer: A, B, C, D

AAN, American Academy of Neurology; AHS, American Headache Society;
CGRP, calcitonin gene-related peptide; mAb, monoclonal antibody.

Importance of Individualized Treatment Plans and Setting Expectations

Because the severity, frequency, and characteristics of migraine vary among patients and, often, within patients over time, and symptom profiles or biomarkers that predict efficacy and AEs for patients have not yet been identified, optimizing treatment for particular patients remains challenging.3

At present, treatment plans are individualized based on the following:3
  • Patient preference
  • Status with respect to pregnancy, lactation, or plans to conceive
  • Frequency and severity of attacks
  • Presence, type, and severity of associated symptoms
  • Attack-related disability
  • Prior treatment response
  • Presence of comorbid and coexistent illness
  • Contraindications (eg, cardiovascular disease)
  • Factors such as body habitus and physiologic measures (eg, blood pressure, heart rate)
  • Use of concomitant medications

A process of trial and error is often necessary before a therapeutic plan can be individualized.3

Additionally, it is important to establish realistic expectations with patients when discussing migraine treatment.3

As outlined in the AHS guidelines, it is crucial that patients understand that any of the following can define success for migraine preventive treatment:3

  • 50% reduction in the frequency of days with headache or migraine
  • Significant decrease in attack duration, as defined by the patient
  • Significant decrease in attack severity, as defined by the patient
  • Improved response to acute treatment
  • Reduction in migraine-related disability and improvements in functioning in important areas of life
  • Improvements in HRQoL and reduction in psychological distress because of migraine

The success of preventive therapy depends on establishing realistic patient expectations for the given treatment(s).3

Despite guideline recommendations of a formal, individualized management plan,3 many patients report not receiving appropriate treatment and follow-up care.2,11

Migraine may have potential long-term clinical and pathophysiological implications for patients if not managed appropriately.12,13

Assessing Effectiveness After Treatment

After initiating a new pharmacologic treatment for migraine or changing an existing treatment, regular follow-up visits are recommended to assess any changes in the frequency and severity of attacks, and to evaluate migraine-related symptoms.14 Follow-up visits are also recommended to identify and address any AEs to the treatment, monitor medication use, and ensure adherence to therapy.14

To accurately evaluate treatment effectiveness, AHS guidelines recommend that patients be assessed after 3 months (after starting monthly treatments), or 6 months (after starting quarterly treatments).3

For a more accurate assessment of treatment effectiveness, it is recommended that patients keep a headache diary to capture changes in attack frequency and severity as well as medication use.3,14 Treatment effectiveness can also be evaluated using a number of available and validated patient-reported outcome (PRO) tools.3 Assessing a patient’s symptoms prior to treatment and routinely throughout treatment can help assess change in duration and severity of symptoms, functional disability, and quality of life (QoL) following therapy.15

After treatment is initiated:
  • Encourage the patient to keep a headache diary to assess treatment efficacy3,14,*
  • Assess the number and frequency of headache days after treatment initiation14
  • Assess the number of days that acute medication is required
  • Use PRO tools to measure duration and severity of symptoms, and assess the impact of treatment on functional disability and improvement in QoL3

*A headache diary should be started as soon as treatment is initiated.

Some examples of validated migraine-specific PRO tools include the Migraine Disability Assessment Questionnaire (MIDAS), 6-Item Headache Impact Test (HIT-6™), and Migraine-Specific Quality of Life Questionnaire (MSQ).3,15 Monitoring treatment effectiveness by assessing reduction in migraine frequency and/or clinically meaningful reductions in the scores of PRO tools can help determine whether a patient should continue treatment, and may facilitate access and reimbursement.3 Furthermore open communication is important and can be as simple as asking open-ended questions to allow the patient to describe his or her experience in his or her own words.15

Disease-specific instruments are more likely to be sensitive to change and reflect the impact of a particular treatment on migraine-related disability.3

Validated instruments that may be used to measure meaningful change after a therapeutic intervention for migraine prevention include:3

  • Patient Global Impression of Change Scale (PGIC)
  • Migraine Functional Impact Questionnaire (MFIQ), a 26-item self-administered instrument for the assessment of the impact of migraine on physical functioning, usual activities, social functioning, and emotional functioning over the past 7 days
  • Migraine-Specific Quality of Life Questionnaire (MSQ v2.1)
  • Headache Impact Test (HIT-6TM)
  • Migraine Disability Assessment (MIDAS)
  • Work Productivity and Activity Impairment (WPAI), a general instrument adapted for migraine that evaluates migraine-related disability and costs

TEST YOUR KNOWLEDGE

Under which criteria does the AHS recommend continuing therapy with a mAb targeting the CGRP pathway? Select all that apply.

A ≥ 50% reduction from pretreatment baseline in monthly headache days or headache days of at least moderate severity

B Clinically meaningful improvement in a validated patient-reported outcome measure (eg, HIT-6™, MIDAS, or MPFID)

C ≥ 25% reduction in monthly headache days

D ≥ 25% reduction in monthly headache days AND clinically meaningful improvement in HIT-6™, MIDAS, or MPFID

Correct

Incorrect
Correct answer: A, B

AHS, American Headache Society; CGRP, calcitonin gene-related peptide; HIT-6™, Headache Impact Test; mAb, monoclonal antibody; MIDAS, Migraine Disability Assessment; MPFID, Migraine Physical Function Impact Diary.

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CGRP and Migraine Pathophysiology

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REFERENCES