Range of preventive therapies should be offered for migraines

LAS VEGAS — To address patient need, affordability and physician-assisted treatment plans, a range of prevention therapies should be offered to those with migraines, according to a presenter at BRAINWeek 2022.

“Patients with migraines can’t always predict the severity of their disease, the level of disability they have,” Merle Diamond, MD, of the Diamond Headache Clinic said during the presentation.

The difficulty in assessing preventive treatment for migraine patients, Diamond stated, is that patients and doctors can be at odds regarding their definitions and goals for prevention. Patients often say they are aiming to no longer have migraines, while doctors often are interested in mitigation strategies.

As such, it is suggested that preventive medications should only be considered for certain patients: those who suffer at least two severe migraines per month or at least four attacks per month, those for whom acute medications have failed, and those who experience hemiplegic and basilar migraines.

According to Diamond, recommended medications fall into one of four main categories: established efficacy, probable efficacy, possibly effective and medications with inadequate or conflicting efficacy data. There is also an “other” group of medications that are possibly or probably ineffective.

In the first category, antiepileptic drugs such as topiramate are suggested, Diamond said, while in the second category, antidepressants such as amitriptyline or venlafaxine are appropriate. In the third category, antihistamines or beta-blockers may be prescribed, while the fourth category involves antithrombotics such as coumadin or antiepileptics such as gabapentin.

In the “other” category, the antiepileptic lamotrigine has been established as not effective, while clomipramine is probably not effective, and clonazepam is possibly not effective.

For all traditional preventive medications, Diamond said, obstacles such as limited or delayed therapeutic onset, limited tolerability and limited patient compliance exist across the board.

Newer therapies, such as monoclonal antibodies that target calcitonin gene-related peptides (CGRP), can be given via either IV or subcutaneous delivery, only need to be administered monthly or quarterly, and are effective for approximately 21 to 30 days, per the presentation.

Also available for migraine prevention are CGRP receptor antagonists Qulipta (atogepant, AbbVie), available in 10 mg, 30 mg and 60 mg tablets and given orally once daily, and rimegepant, which is prescribed at 75 mg every other day, according to Diamond.

Additionally, Diamond stated that neuromodulating devices, which provide nerve stimulation in various cranial locations, and onabotulinum-A injections targeting the forehead and temples offer periodic relief but are limited by cost.

“For patients with chronic migraines that change in frequency and severity is going to take a little bit of time,” Diamond said.