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Migraine Key Clinical Points
Key Clinical Points in Migraine Care: Individualizing Treatment and Prevention Plans

Released: May 14, 2024

Expiration: May 13, 2025

Nada Hindiyeh
Nada Hindiyeh, MD, FAHS
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Key Takeaways
  • Migraine is a debilitating neurologic disease that requires detailed and patient-centered treatment plans.
  • Although triptans are the current first-line treatment options for acute migraine, new options like targeted therapies and noninvasive devices are entering the market.
  • CGRP-targeted preventives should be considered in adults with 4 or migraine days per month and an inadequate response or inability to tolerate 2 or more oral preventives or onabotulinumtoxinA.

Migraine is an undeniably complex neurologic disease that remains underdiagnosed and suboptimally treated. Throughout a series of Medical Minutes, we have gathered knowledge based on research and clinical experience on diagnosing and managing migraine, as well as the importance of patient perspectives and priorities in their migraine journey. We will review the key conclusions of the Medical Minute series below.

Migraine Burden, Diagnosis, and Prevention 
Migraine is a debilitating neurologic disease affecting over 1.1 billion people globally and is the second leading cause of years lived with disability worldwide. Migraine is often misdiagnosed as tension-type headache or mistaken as a sinus headache—leading to ineffective treatment strategies. A simplified, 3-item tool called the ID-Migraine™ can be used to help efficiently diagnosis likely migraine. If a patient answers yes to any 2 questions—1. Light sensitivity with headache? 2. Nausea with headache? 3. Decreased ability to function with headache?—the diagnosis is likely migraine.

Once an accurate diagnosis is made, it is important to discuss appropriate treatment options with patients, as studies show that more than 40% of people with migraine are eligible for preventive treatment but only 16% are currently receiving it. Migraine prevention should be considered in patients who experience frequent or debilitating attacks, overuse acute therapy, or when acute therapy is suboptimal or is patient preference. Thus, it is very important to have a conversation with patients to help empower them to make decisions regarding prevention. 

Acute Migraine Treatment 
All patients with migraine need an acute treatment strategy with a goal of rapid and consistent freedom from pain and associated symptoms and restored ability to function. This requires healthcare professionals (HCPs) to ensure a full and appropriate dose of medication, avoid prescribing opioid and butalbital-containing medications, and encourage the use of a headache diary to track attacks and medication overuse. If treatment is ineffective, HCPs need to think about changing the formulation or route of administration, the drug itself, or whether adjunct or combination treatments are needed for maximal effect. A study on patient perspectives emphasized the importance of complete relief without recurrence as a goal, with less emphasis on route of administration, as patients do not mind trying alternatives to oral therapies, such as nasal sprays or injections.

Triptans are the first-line therapy for acute migraine treatment, but recently newer targeted therapies and noninvasive devices have entered the market. New treatment options, including gepants, ditans, and neuromodulation devices, should be considered if patients have contraindications, an inability to tolerate triptans, or an inadequate response to 2 or more triptans. Acute treatment strategies should be individualized to the patient and may require combinations, nonoral medication options, and the implementation of new acute migraine therapies.  

Patient-centered Solutions to Counseling and Treatment
It is critical to work with patients to create an individualized, proactive treatment plan for migraine prevention and acute treatment using shared decision-making. This may include combination or oral legacy medications with newer treatment strategies, including calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) for migraine prevention or onabotulinumtoxinA for chronic migraine. CGRP mAbs include subcutaneous injections, such as erenumab, galcanezumab, and fremanezumab, or quarterly intravenous infusions of eptinezumab. Options for patients who are needle-phobic include oral CGRP antagonists or gepants, as well as rimegepant and atogepant.

Another significant component of migraine treatment management includes tracking medication overuse headache and addressing it with patients. They need to be guided on how to best treat their individual attacks, while being mindful of the potential for medication rebound and not forgetting to use a treatment when they need it.

Pharmacologic and Administration Considerations With CGRP-Targeted Medications
In the last Medical Minute, we highlighted the latest evidence for preventive treatment options for migraine, including CGRP-targeted medications. These preventives should be considered in adults with 4 or more migraine days per month. A new American Headache Society (AHS) consensus suggests that these therapies should be first-line treatments. Further, 2021 AHS guidelines suggest a CGRP-targeted agent should be tried if there is inadequate response or inability to tolerate 2 or more oral preventives in episodic or chronic migraine or onabotulinumToxinA in patients with chronic migraine. In clinical trials, CGRP mAbs and gepants are effective and safe in the prevention of migraine. Furthermore, research remains ongoing, as there are several more migraine therapies in the pipeline to look out for.

Your Thoughts?
How often do you prescribe CGRP-targeted therapies for your patients with migraine? Get involved in the discussion by answering the polling question and posting a comment below.

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