Preventive Therapy of Migraine

Educational Objectives

The goal of this program is to improve diagnosis and treatment of headache. After hearing and assimilating this program, the clinician will be better able to:

1. Select patients who are good candidates for preventive treatment of migraine.
2. Assess the success of preventive therapies for migraine on the basis of efficacy, tolerability, and patient preferences.

Summary

Prevention of migraine: First interventions should be elimination of triggers of migraine and modification of lifestyle; lifestyle — patient should keep regular schedule, retiring and waking at same times of day; meals should not be missed; if possible, level of stress should be kept low; triggers — vary among patients; patient with migraine should keep daily diary of headaches, medications, and possible triggers; triggers may be difficult to identify and may include red wine (or other alcoholic beverages), poor sleep, change in weather, and stress, overuse of caffeine, withdrawal from caffeine, and use of artificial sweeteners.

Obesity: Not linked to prevalence of migraine; however, obesity associated with increased frequency of migraine or transition from episodic to chronic migraine; contributing factors may include release of proteins from adipose tissue that support inflammatory reaction; obesity may facilitate sensitization; relationship between increased frequency of migraines and obesity may be indirect and related to shared risk factors, such as poor diet, inadequate exercise, anxiety, depression, and sleep disorders.

Overuse of abortive therapies: Use of abortive medications more often than 2 to 3 days per week concerning; guidance from the International Classification of Headache Disorders, Third Edition (ICHD-3) defines medication overuse as using simple analgesics 15 days or more per month or other acute medications 10 days or more per month; clinician should also consider patterns of use; patient with heavy use for single month less concerning than one who consistently overuses medications or increases use over period of several months.

Candidates for preventive therapies: When contemplating preventive agents, clinician should consider frequency, duration, and severity of attacks, efficacy and frequency of use of acute therapies, and preferences of patient; preventive therapy offered when migraine interfering with quality of life despite lifestyle modifications and use of acute therapies; patients using acute medications often at risk for medication-overuse headache; preventive therapy should be contemplated if patient has three or more moderate to severe headaches each month that result in functional impairment and do not consistently respond to acute therapy, or more than 6 to 8 headache days each month, even if headaches respond to acute therapy; other candidates — patients with contraindications to acute therapies; patients with particularly bothersome symptoms (eg, hemiplegic migraine, migraine with brainstem aura).

Selection of medication: Choosing among preventive medications difficult because data limited; clinician may be guided by history of treatment (ie, alternative drug class should be tried if one therapy ineffective); interactions with other drugs, possible adverse effects, and comorbidities must be considered; for example, patient with migraine and untreated high blood pressure may benefit from beta-blocker; costs and patient preferences must be considered.

Counseling patients starting preventive therapies: Clinician should set realistic expectations and explain that adequate duration of course needed to achieve maximum benefit; titration of drug over weeks may be required to reach effective dose; achieving full effect may take several months; drug considered successful if it reduces frequency of migraine by 50% or more; however, decisions about failure or success of therapy subjective; for example, patient who does not achieve goal of reducing frequency of headaches by 50% or more but has significant reduction in severity of symptoms may be satisfied with intervention; drug trial resulting in improvement in migraines but intolerable side effects may be considered failure.

Discontinuing successful preventive therapies: Tapering may be attempted after 3 to 6 months of treatment, but schedule should be dictated by patient preference and pattern of migraines; patients may be unwilling to taper from successful therapies; preventive agents should not be stopped abruptly; frequency of headaches should be monitored during tapering, and dose re-escalated if frequency increases; when tapering, dose may be reduced by approximately 25% every 7 to 10 days.

Compliance with long-term medications: Poor; may be related to failure on part of clinician to set realistic expectations; most common reasons for discontinuing preventive therapies include lack of efficacy and side effects; communication with patients important.

Nonpharmacologic management: OnabotulinumtoxinA — approved by US Food and Drug Administration (FDA) for treatment of chronic migraine, but most insurance carriers do not provide reimbursement unless patient fails to respond to other preventive therapies; onabotulinumtoxinA only FDA-approved therapy for prevention of chronic migraine; drug not approved to treat episodic migraine; neurostimulation — transcutaneous stimulation of supraorbital nerves and transcranial magnetic stimulation recently cleared by FDA; these techniques do not cause systemic side effects; speaker uses these as add-on preventive therapies.

Behavioral interventions: Should be considered for any patient with frequent migraines; options include relaxation training, biofeedback, and cognitive-behavioral therapies; behavioral approaches should be tried for patients who do not respond to or do not want to use other treatments, have contraindications to other therapies, or report that stress significant trigger for migraines.

Emerging therapies: Monoclonal antibodies to calcitonin gene-related peptide (CGRP) ligand or receptor being developed for episodic and chronic migraine; these agents effective and well tolerated; other drugs in development include small-molecule antagonists of CGRP, drugs that target pituitary adenylate cyclase-activating polypeptide, and therapies that target orexins, κ-opioid receptors, nitric oxide synthase, and glutamate.

Readings

Schwedt TJ. Preventive therapy of migraine. Continuum (Minneap Minn) 2018;24(4, Headache).

Disclosures

For this program, the following was disclosed: Dr Schwedt serves on the board of directors for the American Headache Society and the International Headache Society; receives personal compensation as associate editor for Cephalalgia, Headache, and Pain Medicine; and receives personal compensation as a consultant for Alder BioPharmaceuticals, Inc; Allergan; Amgen Inc; Autonomic Technologies, Inc; Avanir Pharmaceuticals, Inc; Dr. Reddy’s Laboratories Ltd; Eli Lilly and Company; Ipsen Bioscience, Inc; Nocira, LLC; Novartis AG; and Teva Pharmaceutical Industries Ltd. He has stock options in Aural Analytics; Nocira, LLC; and Second Opinion. Dr Schwedt has received research/grant support from the American Migraine Foundation, the National Institutes of Health, Patient-Centered Outcomes Research Institute, and the United States Department of Defense. Dr Schwedt has received publishing royalties from UpToDate, Inc. Unlabeled Use of Products/Investigational Use Disclosure: Dr Schwedt discusses the unlabeled/investigational use of numerous medications for the treatment of migraine; none of the therapies discussed are approved by the US Food and Drug Administration except for caloric vestibular stimulation, ,divalproex sodium, erenumab, propranolol, timolol, topiramate, transcranial magnetic stimulation, and transcutaneous supraorbital nerve stimulation for the treatment of migraine and the use of onabotulinumtoxinA for the treatment of chronic migraine. To view disclosures of planning committee members with relevant financial relationships, visit: legacy.audio-digest.org/continuumaudio/committee. All other members of the planning committee report nothing to disclose.

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

CA070405

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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