Interactive Case Challenge - Preventative Treatment for Migraine Patients

CE / CME

Personalized Migraine Prevention: Crafting Proactive Treatment Plans through Shared Decision-Making

Physician Assistants/Physician Associates: 0.50 AAPA Category 1 CME credit

Nurses: 0.50 Nursing contact hour

Physicians: maximum of 0.50 AMA PRA Category 1 Credit™

Pharmacists: 0.50 contact hour (0.05 CEUs)

Released: May 28, 2024

Expiration: May 27, 2025

CME/CE Information

Activity

Progress

1 2

Course Completed

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History Case Follow-up Case Follow-up Case Follow-up Case Conclusion References

Migraine is a chronic and debilitating neurologic disease that often remains underdiagnosed and suboptimally treated. More than 40% of people with migraine are eligible for preventive treatment, but only 16% are currently using a preventive treatment option.¹ Every year, up to 3% of people with episodic migraine will experience transformation to chronic migraine, where they will have 15 or more headache days per month.² This can largely be avoided with appropriate and timely diagnosis, and proactive interventions to prevent and acutely treat migraines.

Frequency, severity, and migraine-associated symptoms vary from person to person and can change over time. Consequently, a trial of various treatment combinations may often be necessary before an individualized therapy plan is solidified. It is also important to consider patient comorbidities, side effects of medications, cost, and patient preference.³

Migraine prevention should be considered in any patient if attacks significantly interfere with daily activity despite acute treatment, if migraines are frequent or intolerable, if there is medication overuse or any contraindications, or the patient has a specific medication preference. Prior to the 2010 approval of onabotulinumtoxinA for the prevention of chronic migraine, only oral medications—many with intolerable side effects—were available for migraine prevention.⁴With the subsequent FDA approval of calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb) therapy for migraine prevention in 2018,⁵ followed by small molecule CGRP antagonists (gepants), a new era for migraine prevention has ensued.⁶

Based on the 2021 American Headache Society (AHS) consensus statement on integrating new migraine treatments into clinical practice, CGRP-targeted therapies should be considered in patients with episodic or chronic migraine after a trial of 2 oral preventive treatments is unsuccessful, or in chronic migraine if at least 2 quarterly injections of onabotulinumtoxinA is ineffective.³

In March 2024, the AHS published an update to their position statement on the use of CGRP-targeted therapies, recommending they be used first-line for migraine prevention. This was based on substantial evidence in their efficacy, tolerability, and safety compared to any other preventive treatment option.⁷ Overall, there are many choices for prevention in migraine, and it is important to develop an individualized plan to treat patients more effectively.

Alice N. is a 43-year-old woman who presents to your clinic with a history of headaches that were diagnosed as migraine. Her headaches have increased in frequency over the last year from just a few per month, to now 16 days per month. Alice attributes this to increased work stress, decreased sleep, and no time for exercise. Her headaches are associated with nausea, vomiting, light sensitivity, and sound sensitivity. She takes acute medications for these attacks and is now using a combination of nasal zolmitriptan 16 days per month, rimegepant 8 days per month, and ondansetron as needed. She has been taking these medications consistently for 4 months. On days she is unable to use a combination of at least 2 acute medications, her migraine attacks can last 24 hours. During those days, she is unable to work or take care of her 2 young children.

Physical Exam:

Vital signs: normal
Neurologic exam: normal

Lab Values: none

Family History:

Both her mother and sister have frequent headaches associated with nausea and light sensitivity

Lifestyle/Social History:

Sleeps irregularly; sometimes 5 and sometimes 7 hours per night
Not exercising currently
Drinks 1 to 3 cups of coffee daily
Does not skip meals and stays well hydrated

Current Medications:

Zolmitriptan nasal spray 16 days/month
Rimegepant 75 mg 8 days/month
Ondansetron 4 mg 10 days/month

What diagnoses best fits Alice’s description?

A .
Medication overuse headache only

10.5%
B .
Chronic tension-type headache

15.2%
C .
Chronic migraine with possible medication overuse headache

67.6%
D .
Episodic migraine with possible medication overuse headache

6.7%

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