CNS SPECTRUMS CME Review Article Current Management: Migraine Headache This activity is provided by the Neuroscience Education Institute. Additionally provided by the American Society for the Advancement of Pharmacotherapy. Downloaded from https://www.cambridge.org/core. IP address: 12.226.147.12, on 25 Jan 2018 at 17:36:41, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1092852917000864 CME Information Date of Release/Expiration Peer Review Released: December, 2017 This content has been peer reviewed by an MD CME credit expires: November, 2020 specializing in psychiatry to ensure the scientific accuracy and medical relevance of information presented and its independence from commercial bias. NEI takes Learning Objectives responsibility for the content, quality, and scientific After completing this activity, you should be better able to: integrity of this CME activity. ∙ Implement evidence-based diagnostic and treatment strategies for patients with migraine designed to Disclosures maximize patient outcomes ∙ All individuals in a position to influence or control Identify pathophysiologic targets of current and investi- content are required to disclose any financial relation- gational therapies in migraine treatment and prevention ships. Although potential conflicts of interest are identified and resolved prior to the activity being Accreditation and Credit Designation Statements presented, it remains for the participant to determine whether outside interests reflect a possible bias in either The Neuroscience Education Institute (NEI) is accre- the exposition or the conclusions presented. dited by the Accreditation Council for Continuing Disclosed financial relationships with conflicts of Medical Education (ACCME) to provide continuing interest have been reviewed by the NEI CME Advisory medical education for physicians. Board Chair and resolved. NEI designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should Author claim only the credit commensurate with the extent of their participation in the activity. Stephen D. Silberstein, MD, is a professor in the The American Society for the Advancement of Department of Neurology and the director of the Pharmacotherapy (ASAP), Division 55 of the American Jefferson Headache Center in the Department of Psychological Association, is approved by the American Neurology at Sidney Kimmel Medical College at Thomas Psychological Association to sponsor continuing educa- Jefferson University in Philadelphia, PA. Dr. Silberstein tion for psychologists. ASAP maintains responsibility for receives research support from Lilly and is a consultant/ this program and its content. advisor to Allergan, Amgen, Avanir, Guidepoint Global, The American Society for the Advancement of Supernus, and Teva. Pharmacotherapy designates this program for 1.0 CE No writing assistance was utilized in the production of credit for psychologists. this article. 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Read the article Additional Peer Reviewer 2. Complete the posttest and evaluation, available only Thomas L. Schwartz, MD, is a professor in and vice online at www.neiglobal.com/CME (under “CNS chair of the Department of Psychiatry at SUNY Upstate Spectrums”) Medical University in Syracuse, NY. Dr. Schwartz has no 3. Print your certificate (passing score = 70% or higher) financial relationships to disclose. Questions? call 888-535-5600, or email Customer- The Content Editor and Planning Committee have [email protected] no financial relationships to disclose. Downloaded from https://www.cambridge.org/core. IP address: 12.226.147.12, on 25 Jan 2018 at 17:36:41, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1092852917000864 Disclosure of Off-Label Use Provider This educational activity may include discussion of This activity is provided by NEI. Additionally provided unlabeled and/or investigational uses of agents that are by ASAP. not currently labeled for such use by the FDA. Please consult the product prescribing information for full disclosure of labeled uses. Acknowledgment of Financial Support Cultural and Linguistic Competency This activity is supported by an unrestricted educational grant from Lilly USA. A variety of resources addressing cultural and linguistic competency can be found at this link: www.neiglobal. com/go/cmeregs Downloaded from https://www.cambridge.org/core. IP address: 12.226.147.12, on 25 Jan 2018 at 17:36:41, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1092852917000864 CNS Spectrums (2017), 22,4–12. © Cambridge University Press 2018 doi:10.1017/S1092852917000864 REVIEW ARTICLE Current management: migraine headache Stephen D. Silberstein* Jefferson Headache Center, Philadelphia, Pennsylvania, USA Migraine varies in its frequency, severity, and impact; treatment should consider these variations and the patient’s needs and goals. Migraine pharmacologic treatment may be acute (abortive) or preventive (prophylactic), and patients often require both. New medication devices are available or in development, including an intracutaneous, microneedle system of zolmitriptan and sumatriptan, and breath-powered powder sumatriptan intranasal treatment. Lasmiditan, a 5-HT1F receptor agonist, is in development for acute treatment, as are small molecule calcitonin gene-related peptide (CGRP) receptor antagonists (Gepants) for acute and preventive treatment. Antibodies to CGRP and its receptor are being developed for migraine prevention. All 4 treatments are effective and have, as of yet, no safety concerns. Received 27 September 2017; Accepted 6 December 2017 Key words: Acute treatment, headache, migraine, monoclonal antibodies, preventative treatment. Introduction function; to decrease recurrence and the need for rescue treatment; and to reduce medical resource use.6 Migraine varies in its frequency, severity, and impact; Acute pharmacologic treatment includes both migraine- treatment should consider these variations and the specific medications, such as triptans and dihydroergot- ’ 1 patient sneedsandgoals. Treatment begins with a proper amine, and nonspecific medications such as acetylsalicylic 2 diagnosis and addressing the impact of the headache. acid (ASA), acetaminophen, and nonsteroidal anti- Education about adverse events, duration of therapy, and inflammatory drugs (NSAIDs). It also includes medications 3 expectations is important. Comorbidity is the association for relief of associated symptoms, such as nausea. Adjunctive of two disorders more likely to occur by coincidence. medications include antiemetics (eg, metoclopramide or Migraine comorbid disorders are listed in Table 1. prochlorperazine) and corticosteroids. Migraine treatment may be acute (abortive) or preventive (prophylactic), and patients may need both. Successful prevention reduces attack frequency. It may also decrease General Principles attack duration or severity and enhance the response to 3 acute treatments, improve function, reduce disability, and 1. The most effective strategy for patients with attacks of 4 reduce healthcare costs. different severity is a “step care within attack” strategy. Early administration of treatment is most appropriate Acute Treatment for consistently moderate or severe attacks that respond well to treatment. This recommendation should be Medications are usually the acute treatment of choice. In a guided by the frequency of the headache. For those with longitudinal study, 91.7% of 11,388 people with episodic near-daily, daily, or continuous headache, caution is migraine reported using pharmacologic treatment for their needed to avoid acute medication overuse. acute migraine attacks.5 The objectives of acute treatment 2. The route of administration depends on the prior are to treat attacks early; to achieve quick, complete pain response to oral therapy, the temporal characteristics relief; to minimize or eliminate adverse events; to restore of the attack, and the presence and timing of nausea and vomiting. Early nausea and vomiting during an * Address for correspondence: Stephen D. Silberstein, Department of attack may impair absorption and bioavailability, Neurology, Thomas Jefferson University, 900 Walnut Street, 2nd Floor, diminishing the efficacy and/or consistency of acute Ste. 200, Philadelphia, PA 19107, USA. medications.7 Non-oral routes of administration (Email: [email protected]) This activity is supported by