SPONSORED CONTENT Migraine Management What Primary Care Providers Need to Know Introduction Migraine can be treated with both Overview of Current Migraine is a long-term, disabling acute and preventive therapies, and Management of Migraine neurologic disease that has a severe patients who experience frequent at- Acute and preventive migraine thera- impact on the lives of patients living tacks may require a multidisciplinary pies have distinct but complementary with it.1–3 Despite this, migraine is approach, which includes a combina- purposes: acute treatments are pri- underdiagnosed and undertreated.4 tion of acute and preventive modali- marily used to abort a migraine attack, Migraine may be classified as chron- ties as well as behavioral interventions while preventive treatments are used ic (≥15 headache days per month as part of their treatment plan.6 This to reduce migraine attack frequency, for more than 3 months) or episod- article aims to provide an overview of duration, and/or severity (Figure 1).6,8 ic (<15 headache days per month).5 available pharmacologic treatments of The American Headache Society There are currently several options for migraine, considerations for their use, (AHS) provides evidence-based recom- managing migraine, including phar- and recommendations for monitoring mendations for initiation of acute and macologic therapy, neuromodulation treatment effectiveness in the primary preventive treatments.6 Acute treat- devices, and behavioral treatments.6,7 care setting. ments are recommended for all indi- viduals with migraine with the goal of Case Highlight: Kelly achieving rapid relief from pain and as- sociated symptoms, and to restore their Kelly, aged 20, was diagnosed with migraine 2 years ago. At diagnosis, Kelly ability to function.6 Currently, preven- spent about 4 to 5 days of the month impacted by migraine. At her last tive treatments should be considered assessment, Kelly said that she felt her migraine attacks were getting worse for patients in the following situations: and occurring more frequently. She reports feeling more sensitive to light higher migraine frequency (≥4 head- and touch during a migraine attack. She usually stays home from work or ache days per month) or attacks that goes home sick about once per month. Furthermore, she often feels too significantly interfere with everyday tired in the evening to spend time on pastimes like reading and sewing, routines despite acute treatment.6 which she used to enjoy. She was offered a triptan as an acute treatment However, patients with fewer head- option, but feels it is not adequate for severe episodes. She says that she ache days per month may still experi- takes it as soon as she experiences early symptoms, especially if she has an ence moderate to severe migraine-re- important upcoming project at work. lated disability.1,2,9,10 In anticipation of attacks, patients may adapt plans and Copyright © 2020 Frontline Medical Communications Inc. All rights This content is sponsored by reserved. No part of this publication may be reproduced or transmitted in Amgen Inc. and Novartis Pharmaceuticals Corporation (NPC). any form, by any means, without prior written permission of the Publisher. Frontline Medical Communications Inc. will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the USA-334-83497 products, drugs, or services mentioned herein. The opinions expressed in this sponsored content do not necessarily reflect the views of the Publisher. adjust their lifestyles, such as not trav- with migraine, 43.3% reported nev- experience at least 4 monthly head- eling alone in case of a migraine at- er having used a migraine preventive ache days, have not been successfully tack.2,11 Preventive treatment may also treatment.1 Interestingly, 32.4% of treated with other preventive agents, be considered if acute treatment is in- this group met the expert panel criteria and report at least moderate disability appropriate because of contraindication for offering or considering preventive as measured by patient-reported out- to acute medications, failure or overuse treatment, which underscores the un- come tools.6 of acute medications, or adverse events met need for preventive therapy in in- associated with their use.6 dividuals who are candidates for it yet Classes of Medication for Evidence to date shows that preven- do not receive it.1 The recent AHS po- Managing Migraine tive medication may be underutilized sition statement provides guidance on Several drug classes are available or in the clinical setting.1 In the American initiation and treatment with calcitonin in development for the acute and/ Migraine Prevalence and Prevention gene-related peptide (CGRP) monoclo- or preventive treatment of migraine study, which evaluated 18,968 people nal antibodies (mAbs) in adults who (Figure 2).6,8,12,13 Treatment decisions may be impacted by a drug’s safety and efficacy profile, patients’ comorbidities Figure 1. Overview of Acute and Preventive 6,8,14,15,18,19 and concomitant medications, and pa- Migraine Treatments tient preference.6,14,15 Both migraine-specific acute med- ACUTE PREVENTIVE ications (eg, triptans, ergotamines, 6,16 Intended to reducemigraine attack and ditans) and non-migraine-spe- frequency, duration, and/or cific acute medications (eg, analgesics 6,8 Used to aborta migraine attack severity6 and nonsteroidal anti-inflammatory Consider forpatientswith drugs)15 are approved by regulatory frequent headaches or those agencies and/or recommended by pro- Appropriate formany with moderatetosevere 6 fessional society guidelines for relief patients headache-related disability6 from migraine attacks. Narcotics and Treatment choice factorsinclude barbiturates are not recommended Possibility foroveruse6,8,18 drug efficacy/safety, concomitant because of their addiction and abuse medications,comorbidities, and 8,15 patient preference6,14,15,19 potential. Although some acute medications are indicated and/or recommended for aborting attacks, acute treatments can Figure 2. Treatment Classes for Acute and/or Preventive be overused, potentially leading to med- Migraine Therapy6,8,12,14,16,20-30 ication overuse headache, a type of sec- ondary headache disorder.5 Medication ACUTE PREVENTIVE overuse headache may occur with acute Anticonvulsant drugs, β-blockers, migraine medications, but is common Triptans, ergots, ditans, oral CGRP mAbs6,14,23 with narcotics and barbiturates; this is CGRP antagonists6,8,16,26 another reason why narcotics and barbi- Neuromodulation devices6 turates should be avoided for migraine Neuromodulation devices6 treatment.8,9,17 Approximately 50% of Neurotoxins12,20 patients with chronic migraine have medication overuse headache that may Antidepressants, ACE inhibitors, NSAIDS, analgesics, opioids6,8 revert to episodic headache after drug angiotensin receptor blockers, 5 alpha-agonists, antihistamines6,14 withdrawal. As such, it is recommended AVOID narcotics and barbiturates6,8,17 that acute treatments are limited to an ≥ 1 compound in each class is FDA-approved for migraine ≥ 1 device in this class is FDA-approved for EM prevention30 average of 2 headache days per week, treatment21,24,25 or for acute treatment of migraine27-30 ≥ 1 compound in each class may be used off-label for migraine 1 neurotoxin is FDA-approved for CM prevention;7 and preventive treatment is considered prevention or for acute migraine treatment, per AAN/AHS this compound is not recommended by AAN for EM12 guideline recommendations6,17,22 for patients observed exceeding this limit.6 Also, it is advised that acute treat- Abbreviations: AAN, American Academy of Neurology; ACE, angiotensin-converting enzyme; AHS, American Headache Society; CGRP, calcitonin gene-related peptide; CM, chronic migraine; EM, epi- ments should not be used in anticipation 2 sodic migraine; FDA, US Food & Drug Administration; mAb, monoclonal antibody; NSAID, nonsteroidal of a migraine attack. anti-inflammatory drug. 1 Traditional preventive therapies in- 2 | Migraine Management: What Primary Care Providers Need to Know clude beta-blockers, anticonvulsants, and antidepressants, which are orally Case Highlight: Kelly administered daily.6,19 Other treatments Because Kelly uses her acute medication often and seems to be starting to use administered by injection once every 1 it in anticipation of a migraine, you worry that Kelly may be at risk of medi- to 3 months include neurotoxins and cation overuse, which could eventually lead to medication overuse headache. anti-CGRP mAbs.6 Neurotoxins are ap- Although Kelly’s migraine frequency is not high, it has a substantially negative proved for the prevention of chronic impact on her quality of life. migraine, while anti-CGRP mAbs are Kelly experiences more than 4 headache days per month with moderate dis- approved for the prevention of both ep- ability, which qualifies her for consideration of preventive medication. You sug- isodic and chronic migraine.6,12 gest that she start with an 8-week trial of a beta-blocker, which has historically established efficacy in migraine prevention.6 Assessing Treatment Effectiveness and Migraine- Related Symptoms more, open communication is import- only chronic, but also episodic migraine After initiating a new pharmacologic ant and can be as simple as asking may have a substantial negative impact treatment for migraine or changing an open-ended questions, to allow the pa- on patients’ lives.6,9,10