ACP releases clinical guidelines for preventing episodic migraines

Key takeaways:

• ACP published three recommendations centered around monotherapy for preventing episodic migraines.
• The organization also suggested informed decision-making and underlined the importance of treatment adherence.

The ACP issued new clinical guidance on preventing episodic migraines, classified as one to 14 headache days per month, in nonpregnant or nonlactating adults in outpatient settings.

The guidance, published in the Annals of Internal Medicine, includes three recommendations centered around monotherapy.

According to the Amir Qaseem, MD, PhD, MHA, FACP, vice president of clinical policy and the Center for Evidence Reviews at ACP, and colleagues, migraines affect around 16% of Americans, with women being more affected compared with men (21% vs. 11%).

They pointed out that migraines, or recurrent moderate-to-severe headaches lasting 4 to 72 hours with or without sensory disturbances, are “underdiagnosed and undertreated... with only a small percentage of eligible people receiving preventive pharmacologic treatments.”

ACP developed its guidance using the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the effects of multiple pharmacologic treatments on outcomes, including migraine frequency and duration, the number of days medications were taken for treatment of migraine, quality of life and physical functioning, frequency of migraine-related ED visits and discontinuations due to adverse events.

The organization also identified further data on adverse events through FDA medication labels and studies.

Recommendations

In the first recommendation, the ACP suggests that clinicians initiate monotherapy to prevent episodic migraine headache in nonpregnant adults in outpatient settings by choosing one of several pharmacologic treatments:

• the beta-adrenergic blockers metoprolol or propranolol;
• the antiseizure medication valproate;
• the serotonin and norepinephrine reuptake inhibitor venlafaxine; or
• the tricyclic antidepressant amitriptyline.

In the second recommendation, the ACP suggests that for nonpregnant patients who do not tolerate or inadequately respond to any of the treatments in the first recommendation, clinicians should use monotherapy with a:

• calcitonin gene-related peptide, or CGRP, antagonist like atogepant or rimegepant; or
• CGRP monoclonal antibody like eptinezumab, erenumab, fremanezumab or galcanezumab.

In the third recommendation, the ACP suggests that if the patients still do not tolerate or inadequately respond to the treatments listed in the prior recommendations, clinicians should use monotherapy with the antiseizure medication topiramate.

Informed decision-making also suggested

Qaseem and colleagues noted that all three recommendations have low-certainty evidence, while clinicians should use an informed decision-making approach and discuss several factors with patients, such as harms, benefits, financial burden, patients’ values and preferences, contraindications, pregnancy and reproductive status for women and clinical comorbidities.

They added that clinicians should explore possible modifiable factors and triggers of episodic migraine before beginning any pharmacological treatment and “discuss the importance of lifestyle interventions, such as staying hydrated and maintaining regular and adequate sleep and physical activity.”

The guidelines also highlighted the importance of patients adhering to treatments because improvement may occur gradually after the initiation of a long-term treatment, “with an effect that may become apparent after the first few weeks of treatment,” the researchers wrote.