Preventative treatment of migraine is underused and should be considered when patients have frequent or severe symptoms. The right approach balances benefits and side effects. Professor Richard Stark of Alfred Hospital and Monash University, Melbourne, Australia, suggested factors clinicians should think about at the World Congress of Neurology 2019.
Migraine tends to be under-diagnosed. When patients have severe recurrent headache, it is usually migraine if the answer to two of the three “ID-Migraine” questions is ‘yes’:1
- In the last three months, has a headache interfered with your activities on at least one day?
- When you have a headache, do you feel nauseated (sick)?
- When you have a headache, does light bother you?
Diagnosis should then be formally confirmed using the ICHD-3 criteria.
Prevention is better than a cure
Once migraine has been diagnosed, each attack can be treated individually to reduce the symptoms. But it is more beneficial if the attacks can be prevented.
Usually the patient will alter their behavior to try to avoid their particular triggers. But when should preventative medications be considered? The answer depends on the frequency and/or severity of the attacks.
Prevention is usually an option if the patient suffers from migraines for more than three days per month. However, other factors that increase disease burden, such as losing a working day each month, could also indicate that preventative medications should be considered.
Preventative medication should be considered for frequent and/or severe attacks
Treatment should be tailored to each individual patient – and there are a large number of options available. However, many patients are treated by general practitioners (GPs) or family physicians. A study of migraine management by Australian GPs found that only 20% of patients with at least three migraine days per month were given preventative treatment. Significantly, when these patients were treated, GPs stuck to only one or two of the available options.2
Guiding principles
Professor Stark outlined aspects of preventative therapy that clinicians should think about. Patients often worry about side effects, and their medical history may indicate medications that are obviously inappropriate. The level of treatment response and tolerance will vary with each patient, but this is very difficult to predict.
Consequently, patients may not take their medications as often as they should. Persistence with the initial oral preventative medication in US patients was only 25% after six months and 14% after a year.3 Patient engagement is important in gaining trust and improving treatment compliance. Other strategies that may help include patient diaries and use of infrequent injectable medications instead of frequent oral ones.
Strike a balance between benefits and side effects
The benefits of treatment tend to be cumulative and dose-related, but keep in mind that side effects are usually dose-related as well. The art of preventative treatment is finding a balance between benefits and side effects. This may involve trying or combining several options, or even rotating between them.
Complicating factors
Clinicians should keep in mind the possibility of dual pathology. Many migraine patients find that pain around the head or neck can be a potent trigger. This means that a head or neck injury can result in a complicated disorder. The patient effectively has two simultaneous problems: primary migraine, and migraine secondary to the injury. In this situation, both causes should be treated simultaneously.
Treatment should be tailored to each individual
Patients who suffer from medication overuse headache tend not to respond as well to preventative therapy, and this should be taken into account.
Dealing with side effects requires data
It is likely that clinicians will need to manage patients who tell them that they aren’t tolerating their treatment, or haven’t tolerated previous treatments from other clinicians. In this situation, it is critical to find out details.
Key information includes the medication(s) involved, the dose(s), and the length of treatment. It is also important to establish whether the patient actually experienced the side effect, or whether they just read the product information and assumed it would occur.
Response and tolerability will vary with each patient
An alternative to medications is treatment with neuromodulation devices. These are non-invasive and are used to stimulate specific nerves. They may be particularly useful for patients who suffer many side effects or who may not be able to take medications for other reasons.
Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.
